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Full text of "U.S. Navy Medicine Volume 69, Number 3 March 1978"

VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADMR.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 
MANAGING EDITOR 

Ellen Casselberry 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contrib uting Editor-in - Ch ief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT R.D. Ulrey (DC); 
Education: CAPT S.J. Kreider (MC); Fleet 
Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.A. 
Olszak; legal: LCDR R.E. Broach 
(J AGO; Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: CDR R,L. 
Surface (MSC); Naval Reserve: CAPT J.N. 
Rizzi (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT S.J. Kreider (MC); Research: CAPT 
J. P. Bloom (MC); Submarine Medicine: 
CAPT J.C. Rivera (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau, of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau c-f Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer: one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery {Code 0010), 
Washington, D.C 20372. Telephone: (Area Code 202) 
254-4253, 254-4316. 254-4214; Aotovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



NAVMED P-5088 



U.S.MVY 




Volume 69, Number 3 
March 1978 



1 From the Surgeon General 

2 Department Rounds 

Tiger cruise teacher . . . NOSC tests blood pressure monitor 

5 BUMED SITREP 

6 On Duty Navy-Indian project combats ear disease 

8 Education and Training 

Masters of defensive driving . . . Landing force medical staff planning 

10 Highlights 

First National Conference on Military Family Research 
E.J. Hunter, Ph.D. 

14 Reserve New wrinkle for Reserve training 

16 Scholars' Scuttlebutt 

Summer's coming (and so is ACDUTRA) . . , Where are the ensigns? 

18 Policy Instructions and directives 

19 NAVMED Newsmakers 

20 Notes and Announcements 

Continuing education for Navy nurses . . . AFIP's annual lectures 
scheduled for June . . . Dental officers selected for advanced training 

21 Features 

Navy Flight Surgeons: From Biplanes to Skylab 
J.M. Devine 

26 Professional 

Bruxism: Emotional Symptom or Dental Occlusal Problem? 
LCDR S.G. Detsch, DC, USN 

COVER: At NRMC Oakland, Navy otolaryngologist CAPT C. Gordon 
Strom (MC) prepares to use an examining microscope. Dr. Strom and 
his colleagues in the Oak Knoll Department of Otolaryngology and 
Maxillofacial Surgery discuss their involvement in an otitis media pro- 
gram for American Indians in the Southwest, beginning on page 6. 
(Photo by PH2 Bob Weissleder.) 



From the Surgeon General 



Maintaining the Quality of Medical Care 



This monthly letter affords an ex- 
cellent mechanism for me to share 
with you my perceptions of where 
we are as a Medical Department 
and where we ought to be. It aiso is 
an excellent way for me to address 
issues that arise in various arenas 
that impact upon us in direct and 
often disquieting ways. I have ad- 
dressed the personnel shortfall in 
this space before, but largely from a 
philosophical view. It is time to ad- 
dress some specific aspects of that 
problem. 

We must not be bound by narrow 
parochial interests which force us to 
maintain facilities where they are 
not needed, and to build new facili- 
ties where they are not justified. We 
cannot put a tertiary care facility at 
the end of every pier. If we do not 
receive the resources to fulfill all 
our requirements, then we are go- 
ing to have to make vertical cuts in 
the services provided. We must 
have the authority to close in-pa- 
tient services in marginal areas if 
necessary, or to close selectively 
specific services at other facilities. 
To do otherwise would be deliber- 
ately accepting an unpalatable and 
indefensible reduction in the quality 
of care provided. 

You are aware of the radiology 
problem and the steps we have had 
to take to provide contract radiologi- 




VADM Arentzen 

cal services at some facilities. For 
some months I have been concerned 
about the ability of the Medical De- 
partment to continue to provide full 
obstetric and gynecology services at 
our facilities. After a comprehen- 
sive review of the situation, it is ap- 
parent that our shortfall of obstet- 
ric/gynecology specialists this 
summer is severe enough to force 
action. It is not possible to absorb 
the shortage through horizontal 
cuts, rendering each department 
anemic and significantly jeopard- 
izing our ability to provide safe, 
quality care. 

Therefore, it has become neces- 
sary to eliminate obstetric /gynecol- 



ogy services at selected Medical De- 
partment activities and redistribute 
the support assets to other Medical 
Department activities to help ame- 
liorate the overall shortage prob- 
lems. In making this decision, cur- 
rent workload and the availability of 
alternative obstetric /gynecology 
services either at other military 
activities or in the civilian commu- 
nity were carefully considered. 

In addition to the already planned 
reductions at New Orleans and Key 
West, closure of the obstetric /gyn- 
ecology services will take place at 
Annapolis, Quantico, Corpus 
Christi, and Port Hueneme. This 
will be phased gradually, so that 
present patients may be carried 
through to delivery and no new pa- 
tients enrolled. 

It is painful at any time to have to 
curtail services. But we must rec- 
ognize that it is no longer possible 
to provide full services everywhere. 
I depend upon each of you to ex- 
plain this necessity to our patients, 
to emphasize that it is in their best 
interests that we maintain quality 
rather than quantity of service. 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 69, March 1978 



Department Rounds 



Tiger Cruise Teacher 



For the USS Coral Sea medical 
department staff, the 1977 Tiger 
Cruise brought an educational bo- 
nus: the aircraft carrier's sickbay 
was transformed into a floating 
medical school under the tutelage of 
Charles R. Hawes, M.D., director of 
the Cardiopulmonary Department 
at Denver Children's Hospital. 

Dr. Hawes was one of 380 guests 
who joined Coral Sea in Pearl Har- 
bor on 29 September for a seven- 
day cruise to the ship's homeport in 
Alameda, Calif. Many of the visit- 
ing "Tigers" were relatives of Coral 
Sea officers and crewmembers. Dr. 
Hawes, for example, was there at 
the urging of his son Bruce, an avia- 
tion structural mechanic attached to 
Fighter Squadron 191, embarked on 
the aircraft carrier. Other guests in- 
cluded fathers, sons, brothers, and 
a grandfather or two. 

Informal. Before coming aboard, 
Dr. Hawes, an associate clinical 
professor at the University of Colo- 
rado, volunteered to conduct in- 
formal training sessions in cardiol- 
ogy for the ship's medical officers 
and corpsmen. Senior medical offi- 
cer LCDR M. Hollis Tanksley (MC) 
quickly accepted the offer and was 
among the 20 medical department 



members on hand for six hours of 
seminars. 

Dr. Hawes enlivened the training 
with slide shows and chalkboard 
drawings, and demonstrated the 
use of a variety of medical equip- 
ment he brought along. 

He paid special attention to the 
hospital corpsmen assigned to Coral 




Dr. Hawes teaches stethoscope use 




Sea. "Now more than ever you are 
called upon to know and do more," 
Dr. Hawes told them, recognizing 
the vital importance of their role in 
Navy health care delivery. "Your 
job has changed into what I call a 
'medical associate.' As such, your 
responsibilities have increased." 

When not teaching, Dr. Hawes 
joined the other guests for shipwide 
tours and briefings on Coral Sea's 
various aircraft. The visitors ob- 
served a high-line conventional un- 
derway replenishment and a vertical 
underway replenishment operation. 

Dr. Hawes received his M.D. 
degree in 1946 from the Oklahoma 
University School of Medicine. He 
is a member of the American Board 
of Pediatrics and the American 
Board of Pediatric Cardiology, and a 
fellow of the American Academy of 
Pediatrics and the American Col- 
lege of Cardiology. 

— Storv submitted bv JOSN Bruce Jones. 
Photos b'v PH3 Rick Lebsack. 




. . . sketches heart functions In training session . . 



. .demonstrates patient care techniques 

U.S. Navy Medicine 



Research 



NOSC Tests Blood Pressure Monitor 



At the Naval Ocean Systems Cen- 
ter, San Diego, work is under way 
on a noninvasive system to continu- 
ously monitor blood pressure, 

NOSC researchers explored vari- 
ous approaches before selecting for 
further development a technique 
using pressure capsule tonometry. 
This technique shows a promising 
capability for continuous monitoring 
of arterial blood pressure in both 
waveform and magnitude. 

Research is sponsored by the 
Naval Medical Research and De- 
velopment Command in Bethesda, 
Md. 

Pressure capsule. The mecha- 
nism used for blood pressure 
sensing in this technique is a pres- 
sure capsule tonometer — a small, 
air-filled chamber which has one 
face of flexible material. A solid- 
state transducer continuously meas- 
ures chamber pressure; the trans- 
ducer's electrical output drives cir- 
cuitry which can produce the wave- 
form and derive instantaneous 
numerical values of both systolic 
and diastolic blood pressure. 

Pressure measurements are taken 
from the radial artery just before it 
crosses over the distal end of the 
radius. At this point the normal 
radial artery is superficial and held 
relatively captive. Also, pressure 
pulsations can be felt most easily 
with the fingertips here, and the 
artery does not shift under the 
tonometer. 

The tonometer, with the flexible 
face down, is held in place and 
pressed against the artery by an en- 
circling wrist band. Although this 
band applies pressure around the 
wrist, there are enough gaps so 
venous flow from the hand is not re- 
stricted. Normal circulation is ap- 
parent in the hand even after the 
band has been in continuous use for 
one hour; also, bi-directional dopp- 
ler flow measurements on a number 
of superficial arteries in the hand 



reveal no arterial occlusions. 

In the first designed system, elec- 
trical signals representing arterial 
pressure from the tonometer are 
processed by a microprocessor. 
Using timing provided by a simul- 
taneously acquired Lead I electro- 
cardiogram, the microprocessor 
digitizes the pressure wave, identi- 
fies systolic and diastolic pressure 
points for each beat, displays both 
values digitally, and converts sys- 
tolic and diastolic values to analog 
form for recording on a strip chart. 

Because pressure variations 
caused by the patient's breathing 
may obscure trends, the micro- 
processor has been programmed to 
calculate a moving average of the 
last n beats before display or out- 
put, where n can be selected as 2, 4, 
or 8. In addition, the microprocessor 
uses the EKG signal to calculate 
beat-to-beat heart rate, which is 
shown on a third digital display for 
either an individual beat or a 
moving average (as is done with 
blood pressure measurement). All 
three digital displays are updated 
with every heartbeat regardless of 
the averaging interval that is se- 
lected. 

Presently, the tonometer is not 
automatically calibrated to actual 
intra-arterial pressures, but this is a 
design goal. Although representa- 
tive of the blood pressure wave- 
form, the monitored wave by itself 
is not an absolute measure of blood 
pressure. Also, positioning the 
tonometer over the artery is critical 
for fidelity of waveshape and stabil- 
ity. The tonometer must be care- 
fully placed and cannot be moved; if 
the wave baseline is to remain 
stable over any measurement peri- 
od, the wrist must be immobilized. 

Studies. Solutions to these prob- 
lems are being sought through addi- 
tional research studies. For exam- 
ple, research performed at the 
Medical School of the University of 



California. San Diego, by NOSC 
biomedical engineers compared 
tonometer pressure with pressure 
obtained from indwelling catheters 
in dogs. The tonometer was located 
on the skin over the left femoral 
artery; the catheter was placed in 
the right femoral artery. Systolic 
and diastolic pressures were meas- 
ured by the tonometer, which was 
initially scaled with the indwelling 
pressure measurements as a refer- 
ence. The goal: to determine if, 
once set, the pressure wave pro- 
duced by the tonometer tracked the 
pressure wave of the indwelling 
catheter. 




Navy researchers work on blood pres- 
sure capsule tonometer recordings 

Scaling was not changed as a 
number of cardiovascular-altering 
drugs were administered. Epineph- 
rine, norepinephrine, isoproterenol, 
and acetylcholine were used to en- 
sure a wide range of pressure 
waves. 

The concentrations used for the 
drugs resulted in marked pressure 
wave alterations. For large pressure 
variations, the tonometer values 
were not always proportional to 
catheter values, although they al- 
ways followed the direction of the 
changes. For small changes, there 
was close correlation between the 
tonometer and catheter values. 



Volume 69, March 1978 



Figure 1 shows catheter pressure 
waveform, tonometer pressure 
waveform, and derived systolic and 
diastolic pressures for the dog when 
no drugs were administered. Sys- 
tolic and diastolic pressures indi- 
cated by the tonometer can be seen 
to closely track those of the catheter 
even through respiratory pressure 
dips. Also, the tonometer wave is 
closely in phase with the catheter 
wave even though the frequency 
response of the tonometer is con- 



siderably below that of the catheter. 
(Calculations show the tonometer to 
have an acceptable response up to 
10 Hz.) 

Figure 2 is a 100-second record- 
ing of pressure data with systolic 
and diastolic pressures when drugs 
were administered. The dog was 
recovering from one drug (acetyl- 
choline) up to the point indicated by 
the arrow, at which time a second 
drug (a bolus of isoproterenol) was 
injected. 



Volunteers. In addition, compara- 
tive measurements of tonometer 
and catheter are being carried out 
on human volunteers at Naval Re- 
gional Medical Center, San Diego. 
These volunteers are patients who 
already have radial artery catheters 
in place as a normal part of their 
medical treatment; no drugs are 
given during the tests, and the pa- 
tients are placed at no additional 
medical risk as a result of their par- 
ticipation in the experiment. 











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FIG. 1. Simultaneous tonometer and catheter recordings for 
dog without drugs. Tonometer was placed over left femoral 
artery; Indwelling catheter was in right femoral artery. Micro- 
processor-derived beat-to-beat systolic and diastolic pres- 
sures are also shown. 



FIG. 2. Simultaneous tonometer and catheter recordings 
for dog with drugs. Dog was recovering from acetylcholine 
when isoproterenol bolus was injected at point indicated by 
arrow. 











■ 


Aittttkaan^. uiuui 




■ 




































FIG. 3. Simultaneous tonometer and catheter recordings from FIG. 4. Simultaneous tonometer and catheter recordings for 
human patient under conditions of normal cardiac activity. human patient under conditions of abnormal cardiac activity. 



U.S. Navy Medicine 



The radial artery site opposite the 
catheter is used. Since the wrists 
are not immobilized, waveform sta- 
bility is limited to short periods, 
generally of less than a minute. 

Tonometer measurements for a 
human patient are shown in Figures 
3 and 4. Figure 3 represents a 40- 
second recording during a period of 
normal cardiac activity. There is 
general agreement between the two 
pressure waveforms and respiratory 
variation can be observed in both 
tracings. (In this case tonometer- 
based and catheter-based measure- 
ments both have approximately the 
same band limitation of 10 Hz.) 

Figure 4 records the same pa- 
tient over a period of abnormal car- 
diac activity. Pressure wave charac- 
teristics for the individual abnormal 
beats as measured by the tonometer 
match those of the indwelling 
catheter. This particular result 
shows that even if the tonometer is 
not absolutely calibrated to pres- 
sure values, waveform information 
can be accurately obtained; it 
suggests that in the presence of 
abnormal EKG activity, the tonome- 
ter might add hemodynamic infor- 
mation in support of a diagnosis. 

The tonometer has also been used 
to demonstrate pressure wave char- 
acteristics in the carotid artery and 
in the dorsalis pedis artery in the 
foot. At the carotid artery, the 
tonometer gives results equivalent 
to a standard carotid pulse tracing. 

On the basis of experimentation 
to date, the pressure capsule to- 
nometry approach appears suffi- 
ciently promising to warrant further 
development. Even if calibration 
and stability problems cannot be 
solved, the technique would still be 
of value as a noninvasive means of 
recording samples of pressure 
waveshape. But if the problems can 
be solved, the technique has the 
potential for widespread application 
wherever continuous monitoring of 
blood pressure without catheteriza- 
tion may be desired for patient diag- 
nosis and treatment. 

— W.T. Rasraussen, Ph.D., head. Biomed- 
ical Engineering Branch, Naval Ocean Sys- 
tems Center, San Diego, Calif. 92152. 



BUMED SITREP 



CONSTRUCTION . . . Seven Navy med- 
ical construction projects remain sched- 
uled for completion during Fiscal Year 
1978: 

• Phase II of the Environmental Health 
Effects Laboratory at the Naval Medical 
Research Institute, Bethesda. This labo- 
ratory will provide facilities for under- 
water research projects in pressures up 
to 1,500 psi and in closed systems (sub- 
mersible) environments. 

• A medical and dental clinic addition 
for the ADM Joel T. Boone Clinic at 
Naval Amphibious Base, Little Creek, 
Va. The addition will include a medical 
clinic for active-duty military personnel 
and a dental clinic with 26 dental 
operating rooms and 6 oral hygiene 
treatment rooms. 

• Modernization of NRMC Jackson- 
ville, Fla., to upgrade clinical facilities 
as well as mechanical and electrical sys- 
tems in the hospital. 

• Replacement of the medical clinic at 
Sewells Point, Naval Base, Norfotk, 
with a consolidated clinic that will serve 
both the naval base and the naval air 
station. 

• A branch dental clinic at Naval Air 
Station, North Island, to include 22 
dental operating rooms and 5 oral hy- 
giene treatment rooms. The new clinic 
will replace a substandard cantonment 
facility built during World War II. 

• A new facility for Navy Environ- 
mental and Preventive Medicine Unit 
No. 5 at San Diego, also replacing a sub- 
standard WWII cantonment building. 

• A branch medical and dental clinic at 
Naval Air Station, Brunswick, Maine, to 
replace a substandard WWII canton- 
ment facility. 

New construction projects authorized 
last August in the FY78 Military Con- 
struction Program include bachelor en- 
listed quarters at NRMC Bremerton, 
Wash.; a new parking structure at 
NNMC; and steam line distribution re- 
pairs at NRMC Portsmouth, Va. — an 
Energy Conservation Investment Pro- 
gram project. 

Included in the Medical Department's 
proposed construction program for 
FY79 is a major hospital replacement 
project at NRMC Camp Lejeune, N.C. A 
replacement dental clinic at Naval Re- 
gional Dental Center, Norfolk, Va.; a 
branch medical and dental clinic at The 
Basic School, Marine Corps Develop- 
ment and Education Command, Quan- 



tico, Va.; an Industrial Health Clinic, 
Marine Corps Air Station, Cherry Point, 
N.C; a replacement Biomedical Re- 
search Laboratory at Naval Medical Re- 
search Unit No. 3, Cairo, Arab Republic 
of Egypt; and Phase III of center rede- 
velopment at NNMC Bethesda, Md., 
constitute the remainder of the pro- 
posed construction program. 



IMMUNIZATION MEDIA KITS . . . 

BUMED has available for distribution a 
limited number of free immunization 
media kits prepared by the Center for 
Disease Control. The kits contain photo- 
graphs, artwork, fact sheets, and other 
useful material that will help Navy med- 
ical facilities inform their patients about 
the need for childhood immunizations. 
Kits may be obtained from: Editor, U.S. 
Navy Medicine, Bureau of Medicine 
and Surgerv (Code 0010), 2300 E St. 
NW, Washington, D.C. 20372. One kit 
per facility, please. 



EQUAL OPPORTUNITY . . . BUMED is 

looking for an officer, preferably LCDR 
or above, to serve with its equal oppor- 
tunity specialist teams as officer-in- 
charge of the West Coast detachment. 
The selectee will attend the Defense 
Race Relations Institute for 11 weeks 
before assuming OIC responsibilities. 
During the OIC tour of duty, the detach- 
ment will travel to San Diego, Great 
Lakes, and Corpus Christi to implement 
Phase II of the Navy Equal Opportunity 
Program. Interested persons should 
contact LT B.J. Jones (MSC), Bureau of 
Medicine and Surgery, Code 354. Tele- 
phone: (Area code 202) 254-4081 or 
Autovon 294-4081. 



FMF MEDICAL SUPPORT ... The 

Medical Officer, U.S. Marine Corps, 
will hold the third annual "Conference 
of Selected Medical Department Offi- 
cers of Marine Corps Commands" from 
24 through 28 April 1978. The confer- 
ence will focus on matters pertaining to 
overall medical support for the Fleet 
Marine Forces. Specific topics and 
agenda items are currently being solic- 
ited. For additional information contact 
the Medical Officer's Office, HQMC, at 
Autovon 224-1055/1537 or Commercial 
(202) 694-1055/1537. 



Volume 69, March 1978 



On Duty 



NRMC Oakland 



Navy-Indian Project Combats Ear Disease 



In the last decade, otitis media 
has replaced tuberculosis as the 
major reportable health problem 
among American Indians. 

Now, through the Navy- Indian 
Otitis Media Project, the staff of the 
Otolaryngology and Maxillofacial 
Surgery Department at Naval Re- 
gional Medical Center Oakland is 
helping control that problem on 13 
Indian reservations throughout Cali- 
fornia, Arizona, Nevada, and Utah. 

CAPT Tom Miller (MC), depart- 
ment chairman, remembers how the 
project began nearly five years ago: 

"The Phoenix Indian Hospital 
wasn't able to care for a large back- 
log of otitis media patients on the 
seven reservations in the area. The 
disease was so prevalent and there 
were such demands for prolonged 
treatment, corrective surgery and 
rehabilitation, that the single otolar- 
yngologist at that hospital just 
couldn't handle it all." 

Call for help. By then Congress 
had appropriated funds expressly 
for an otitis media program, and a 
hospital administrator at the Indian 
Health Service Hospital on the Fort 
Apache Reservation in Whiteriver. 
Ariz., called NRMC Oakland for 
help. 

"The Phoenix Area of the Indian 
Health Service has the task of pro- 
viding medical care to the Indian 
population throughout the South- 
west. They had asked other govern- 
ment health providers to help sup- 
ply extra medical care to identify 
and treat otitis media," explains 
CAPT Patrick R. Burkett (MC), as- 
sistant chief of the department. 
"Because of the availability of our 
personnel, we were able to deliver 
services beyond what we were al- 
ready providing for the military." 



When the project began, two 
or three patients were flown each 
week from Whiteriver to Oakland 
Internationa] Airport. There they 
were met by an ear, nose, and 
throat technician who brought them 
to the medical center for surgery. 

The other part of the project in- 
volved Oak Knoll physicians visiting 
Whiteriver to see Indian patients in 
clinics. 

"There was a great need for our 
help," says CAPT Burkett. "In the 
first several clinics we held we iden- 
tified up to as many as half of the 
Indians examined as needing treat- 
ment for chronic ear disease, either 
because of chronic infection or ear 
drum perforation — or both." 

"The initial response to our ear 
clinics on the reservation was one of 
unconcern, bordering almost on dis- 
trust," CAPT Miller recalls. "The 
Indian has been the object of so 
many survey projects and short 
term pseudocharitable efforts, with 
no resulting benefit, that this reac- 
tion didn't surprise us." But, ac- 
cording to Dr. Miller, as the otitis 
media project stretched from weeks 
into months and finally into years, 
the Indians' response changed to 
total acceptance, warmth, and real 
appreciation for the efforts being 
made in their behalf. 

On the reservation. More than 
700 Whiteriver Indians have been 
treated since the project began. 
And with the help of funds from the 
Public Health Service, CAPT Miller, 
CAPT Burkett, and their colleague 
in the Otolaryngology and Maxillo- 
facial Surgery Department, CAPT 
C. Gordon Strom (MC), have regu- 
larly conducted similar clinics at 
many other reservations in the 
Southwest. 



But all surgery is performed at 
Oak Knoll, and weekly charter 
flights still bring the ailing Indians 
in for treatment. 

"We meet the Indians at the air- 
port and check them in at Oak Knoll 
for examinations and a tour of the 
facilities," says CAPT Strom, chief 
of the Otology and Pediatrics Divi- 
sion. "Wives' club members and 
others also take them on a tour of 
San Francisco. After surgery, 
they're on their way home within a 
week." 

Surgery has ranged from a simple 
adenotonsillectomy to the most 
complicated tympanoplasty and 
tympanomastoid procedures. 

Benefits for all. "The Phoenix 
area Indian Health Service provides 
funds for transportation, travel, 
equipment, and the extra personnel 
necessary to do the job," CAPT 
Strom explains. "And the program 
has always been conducted with the 
permission of our commanding offi- 
cer and with the assurance that 
other treatment in our department 
wasn't held short." 

The Oak Knoll otolaryngologists 
see the program as benefiting the 
Navy as well as the Indians. "You 
learn something different every 
time you do surgery for otitis 
media," Dr. Strom says. "Our ex- 
perience with American Indians and 
their ear diseases has helped us 
care for patients from our own mili- 
tary community." 

CAPT Burkett is particularly 
pleased by the improvement in the 
health of Indian children he sees. 

"Probably the most important 
thing we've noticed is that the in- 
cidence of otitis media has de- 
creased markedly with good treat- 
ment of the initial infection in the 



U.S. Navy Medicine 



children," he says. "Treating the 
disease where there isn't a perfora- 
tion of the ear drum seems to cause 
the disease to disappear with no 
permanent disability." 

Mini-residency. Another vital 
part of the program has been in- 
hosprtal training of Public Health 
Service physicians, nurse practi- 
tioners, and physician's assistants. 
Selected representatives come to 
NRMC Oakland for one week to ob- 
serve ear surgery and receive in- 
struction in postoperative care of 
the patient. The goal: to enable 
them to care for ear disease on the 
reservation. 

'"This mini-residency in otolaryn- 
gology has been praised by the Pub- 
lic Health Service as one of the most 
valuable fringe benefits of the pro- 
gram," Dr. Miller reports. 

Besides the otitis media project, 
other innovations at the Department 
of Otolaryngology and Maxillofacial 
Surgery include a regional hearing 
conservation program aimed at re- 
ducing the number of disabled and 
handicapped service members and 
Navy employees. In five separate 
courses at Oak Knoll, 76 audio- 
metric technicians have been 
trained; they are now working in the 
region performing initial hearing 
tests and keeping hearing conserva- 
tion records under the supervision 
of environmental health specialists. 

"We've done a lot of new things 
here at Oak Knoll." says Dr. 
Miller, "and as a result we've built 
up a program that has a reputation 
as good as the university pro- 
grams." 

Dr. Burkett agrees. "We've been 
able to provide most of the latest 
developments in medical care 
here," he says of his work at NRMC 
Oakland. "In our department the 
overall quality of care is excellent. 
We have a very good ratio of staff 
physicians to residents, which 
means better resident training and 
better patient care both here and at 
the outlying military clinics in the 
region." 

— Story submitted by J03 John Brindley. 
Photos by PH2 Bob Weissleder. and courtesy 
of The Oak Leaf. NRMC Oakland. 

Volume 69, March 1978 




Dr. Miller examines youngster at Oak Knoll's ENT clinic 




Education & Trainin 



a. 



Navy ambulance drivers learn to be , 



Masters of Defensive Driving 



For many years after the driven 
ambulance was introduced in 1906, 
most ambulances were nothing 
more than converted funeral home 
hearses. The design of the hearse 
made it easy to transport injured 
patients on portable litters. Few 
medical supplies were carried, and 
only as many attendants as could 
squeeze into the cramped space. 

Today, specially designed vehi- 
cles carrying sophisticated medical 
equipment serve as ambulances in 
most of the country's urban areas. 
Use of these larger, less maneuver- 
able ambulances requires that 
drivers be thoroughly trained in all 
aspects of safe handling. 

At the Naval Regional Medical 
Center Corpus Christi, Tex., three 
state troopers from the Education 
Section of the Texas Department of 



Public Safety recently conducted a 
class in professional defensive driv- 
ing. Thirty-five people from the 
hospital — including ambulance 
drivers, attendants, and transporta- 
tion drivers — participated. 

High aim. The course began with 
an intensive three-hour classroom 
session of films, lectures, and five 
tests. Students then went on the 
road to master four vehicle maneu- 
vers designed to make them aware 
of the van ambulance's limitations. 

In this road course, students 
learned how to handle a diminishing 
alley, a 90° right turn, an offset 
alley, and patient loading area 
maneuvering. The instructors con- 
tinually reminded each driver that 
speed was not important, and at no 
time did the drivers exceed 20 miles 
per hour. Instead of speed they con- 




State Trooper J.D. West conducts classroom session in defensive driving 



centrated on driving the vehicle so 
skillfully that it did not hit the 
boundary flags or pylons placed 
along the course. Each driver 
started the course with a perfect 300 
score and lost five points every time 
a stanchion was touched. 

The first hurdle, the diminishing 
alley, was a test of the drivers' 
"high aim" driving skills. Drivers 
had to enter a 9-ft-wide lane bor- 
dered by stanchions which gradu- 
ally reduced the lane to a width of 
only 7 ft. Drivers were to maintain a 
speed of 20 mph while driving 
through the 200-ft-long alley. 

The right turn test challenged the 
drivers' breaking and distance judg- 
ment skills. Drivers had to enter a 
marked off lane at 20 mph, drive 50 
ft, negotiate a 90° right turn, then 
with only 100 ft of lane remaining, 
increase vehicle speed back to 20 
mph. From this test, drivers learned 
an important lesson: van ambu- 
lances cannot be driven like regular 
automobiles because the center of 
gravity is higher in an ambulance 
and farther away from the driver, so 
it takes longer to stop. 

Tough test. The next maneuver, 
the offset alley, proved to be tough 
for the students, and many drivers 
lost points. This test simulated 
guiding an ambulance into an 
accident scene, then backing the 
vehicle along the same path it 
entered. The test was complicated 
by a sharp swerve in the middle of 
the path, which was difficult for the 
driver to see through the ambu- 
lance's rear window. 

The final obstacle, the patient 
loading dock, was the most difficult 
of the four tests. Drivers had to 
guide the vehicle into a 10-ft drive- 
way and back up from there into a 
simulated patient loading dock; 
then they had to drive out the same 
way they came in. This test also 
simulated backing an ambulance 



U.S. Navy Medicine 




Points off for each stanchion hit 




The 90° turn is tricky 



H 




Diminishing alley tests aim 




into an accident area between two 
vehicles or buildings. 

The 35 medical center personnel 
who took the course scored an aver- 
age of 250 points. 

The obstacle course helped driv- 
ers learn the limitations of their 
vehicles and themselves — limita- 
tions which might be corrected 
through training. This training can 
be incorporated into the hospital's 
program for all prospective ambu- 
lance drivers, and can be offered as 



an annual refresher course. At 
Corpus Christi, medical center 
transportation personnel them- 
selves will be able to conduct future 
courses. 

This professional defensive driv- 
ing course was conducted at no cost 
to the medical center thanks to the 
Texas Department of Public Safety 
and the men who administered the 
course: State Troopers James I. 
Anderson, William M. Smith, and 
J.D. "Chick" West. 



Landing Force Medical 
Staff Planning 



Visibility to rear is poor 

Volume 69, March 1978 



The Landing Force Training Com- 
mand, Pacific (LFTComPac), lo- 
cated aboard the Naval Amphibious 
Base, Coronado, near San Diego, 
\J.'*fc:| Calif., sponsors instruction and 
training in the doctrine, tactics, and 
techniques of amphibious opera- 
tions, with emphasis on landing 
force matters. 

Included in the training is a five- 
day landing force medical staff 
planning course. Its purpose: to 
train health service officers and 
selected medical department petty 
officers and noncommissioned offi- 
cers of the U.S. and allied armed 
forces in the principles and tech- 
niques of medical staff planning and 
landing force medical services in 
amphibious operations. 

The course emphasizes the con- 
siderations and responsibilities of 
the landing force commander and 
amphibious task force commander 
in providing medical support. After 
completing this training, students 
should be able to prepare medical 
estimates, casualty estimates, and 
medical annexes and plans. 

The course specifically addresses 
the following areas: amphibious 
task force organization and relation- 
ships; landing categories and seri- 
alization; intelligence planning; civil 
affairs organization and functions; 



shore party and helicopter support 
team operations; medical battalion 
communications; embarkation plan- 
ning considerations; amphibious 
logistics; logistic control agencies; 
administrative-logistics plans; and 
medical staff planning problems. 
The training involves classroom 
work only; practical field training is 
not included. 

Training in landing force medical 
staff planning is conducted through: 

• resident courses, "as request- 
ed," at the Naval Amphibious Base, 
Coronado. 

• mobile training team courses — 
provided the requesting command 
can furnish the areas, classrooms, 
and facilities, and defray all attend- 
ant temporary additional duty costs 
of team personnel and transporta- 
tion charges for instructional mate- 
rial. 

• unit training, conducted in ac- 
cordance with arrangements deter- 
mined during planning conferences 
and discussions (training of major 
units and special groups is conduct- 
ed by LFTComPac on an "as re- 
quested" basis). 

Approximately 350 Navy Medical 
Department and Marine Corps 
members attended the courses dur- 
ing 1976 and 1977. 
— LCDR R.W. Barnhill (MSC). 



Highlights 



First National Conference on Military 
Family Research 



Edna J. Hunter, Ph.D. 



A conference on current trends and directions in military family research 
was held 1-3 Sept 1977 in San Diego. Joint hosts for this conference were 
the Family Studies Branch of the Naval Health Research Center, San 
Diego, and the Naval Postgraduate School, Monterey, Calif. Funding was 
provided by the Office of Naval Research. 

The conference gave researchers and Navy operational decision- makers 
an opportunity to examine the entire spectrum of military family research 
— what has been done, what is being done now, and the directions such re- 
search should pursue in the future. In attendance were representatives 
from all branches of the military service as well as the academic commu- 
nity. Participants and attendees included operational, research, and 
service delivery personnel. The conference was evidence of growing inter- 
est in the military family; it also demonstrated that top planners now real- 
ize that while the military organization has an impact on family members, 
the family also impacts upon accomplishment of the military mission. 

Keynote speakers representing the three military services were VADM 
James D. Watkins, USN, Chief of the Bureau of Naval Personnel; BGEN 
John H. Johns, USA, Chief of the (Army) Human Resources Directorate; 
and BGEN Richard Carr, USAF, Deputy Chief of (U.S. Air Force) Chap- 
lains. 

The opening plenary session was introduced by RADM D. Earl Brown, 
MC, USN, commanding officer of Naval Regional Medical Center San 
Diego; it was closed by RADM John J. 'Connor, CMC, USN, Chief of 
Navy Chaplains. Principal speakers on the opening day included Professor 
Henry B. Bitter of the University of Rhode Island, and retired ADM Elmo 
R. Zumwalt, Jr., former Chief of Naval Operations. 

Edna J. Hunter, Ph.D., head of the Family Studies Branch, Naval Health 
Research Center, was conference general chairman. D. Stephen Nice, 
Ph.D., also of the Naval Health Research Center, served as program chair- 
man, and Professor C. Brooklyn Derr of the Naval Postgraduate School was 
administrative chairman. 



Until recently, military family re- 
search has been a much-ne- 
glected area of concern among 
military planners, even though the 
research that has been carried out 
usually pointed to a definite rela- 
tionship between family factors and 
the job satisfaction, performance, 
and retention of service members. 

Dr. Hunter is head of the Family Studies 
Branch, Naval Health Research Center, San 
Diego, Calif. 92152. 

Photographs courtesy of Virginia Sieg- 
fried, Wifeline. 



The all-volunteer service, the 
changing roles of men and women 
in society, and the integration of 
larger numbers of women into mili- 
tary service have increased interest 
in the family's impact upon the mili- 
tary mission. 

In his keynote address, VADM 
Watkins observed that the military 
services have not been very sophis- 
ticated about measuring the value 
or impact of family support efforts. 
"Lack of solid data has not only 
made it difficult to define our 



requirements, but has also made it 
difficult to defend resulting pro- 
grams — particularly those in com- 
petition with programs more obvi- 
ously related to readiness," he said. 

As an example, VADM Watkins 
noted that of the total Department 
of Defense research and develop- 
ment budget, for every dollar allo- 
cated to hardware programs only 
half of 1 % goes into personnel re- 
search. Yet operational planners are 
constantly confronted with the fact 
that military manpower accounts for 
55% of the Defense budget annually 
— an index cited as excessive even 
though industry nationally spends 
70% of its budget for labor and re- 
lated costs. Nonetheless, when 
budget time rolls around each year, 
planners, analysts, and civilian mili- 
tary leaders focus on hardware- 
oriented military capabilities and 
the readiness of the services to 
carry out their combat missions, 
VADM Watkins said; budget items 
not directly coupled with readiness 
are often vulnerable to curtailment. 

ADM Zumwalt, drawing upon his 
vast naval experience, said that 
most Line officers have used some 
form of research to try to under- 
stand the problems of the people 
under their command. However, in 
past years the military commander 
usually was his own research ana- 
lyst, and "poor man's research" 
was about the only type available to 
him. Unfortunately, as BGEN Johns 
pointed out, "good common sense" 
sometimes led to actions that were 
not always the best. 

VADM Watkins affirmed that, on 
the other hand, "good, solid, well- 
constructed and properly coordi- 
nated research . . . will give us the 



10 



U.S. Navy Medicine 



data we need to defend our pro- 
grams against the most detailed and 
objective scrutiny." But, he said, 
most reports of past research are 
filed away on "dusty shelves." 

"Few of these [reports] have ever 
been reviewed by people who had 
the power to change policies and 
programs," VADM Watkins said. 
"Yet people who can influence poli- 
cies directly or indirectly affect mili- 
tary families in hundreds of ways." 

He pointed out that this situation is 
changing, and said that the 400 
persons attending the conference 
were positive evidence of the inter- 
est in that change. 

OPERATIONAL PAYOFFS 

Too often research studies have 
been designed solely to serve aca- 
demic pursuits, whereas the needs 
of military planners are basically 
pragmatic. Conference speakers re- 
peatedly emphasized the need to 
translate research findings into 
meaningful, applicable, and helpful 
information for operations person- 
nel. VADM Watkins underlined this 
need saying, "While theory is cer- 
tainly important in the development 
of a study, hard data must support 
the application of the results in 
today's world .... While opinions 
are necessary in forming conclu- 
sions, the budget analysts in the 
Congress want to see measurable 
payoff." 

With the end of the draft and the 
loss of unlimited manpower re- 
sources, the need to use information 
derived from research to increase 
operational effectiveness has be- 
come even more acute than it was in 
the past. A host of questions still 
challenge researchers: Which sup- 
port systems best meet the military 
family's needs? Are new social or 
financial supports required? Are 
there perhaps different supports 
required at transitional points in the 
family's developmental life cycle — 
for example, when the first child 
arrives or when the military mem- 
ber retires from active duty? Do the 
programs set up to support families 
really do the job? Often Navy plan- 



ners don't know the answers to 
these questions because Navy pro- 
grams haven't been properly evalu- 
ated. 

Family practice clinics are now 
beginning to assess family function- 
ing as a routine part of family health 
care. More health care providers 
now realize that family crises, life 
events and physical health are 
related, and all affect the demand 
for health care services. One direct 
payoff of research, then would be to 
limit the increased demand for 
health care services that usually oc- 
curs among family members im- 
mediately after the father deploys. 
Adequate support systems that 



is indeed a problem to the Surgeon 
General and to the Assistant Secre- 
tary of Defense for Health Affairs. 
. . . Our interests are in developing 
more information about consumer 
health behaviors — how people use 
health facilities — as well as the 
effect of stresses on health, both for 
family members and service mem- 
bers." 

Research is needed, for example, 
to find out if assigning women to 
sea duty or combat assignments in- 
creases, decreases, or has no impact 
upon retention, performance, and 
family satisfaction with the military 
lifestyle. ADM Zumwalt said he be- 
lieves strongly that women at sea 























^■^>^B 


Ti i^OH 








i,\ n • 



ADM Zumwalt scores a point, while Drs. Hunter and Biller listen appreciatively 



effectively meet the crises that ac- 
company family separations could 
perhaps considerably reduce the 
family's demand for expensive med- 
ical services. 

CAPT Paul D. Nelson <MC), of 
the Naval Medical Research and 
Development Command, told con- 
ference participants that his organi- 
zation is interested in knowing 
"how families prepare for separa- 
tion, how they cope with it when 
under way, and how the family 
comes back together again, particu- 
larly from the point of view of health 
needs." 

"The consumer market for health 
needs in the military is enormous, 
and though more and more of this is 
going out via CHAMPUS to civilian 
providers, it still costs money to the 
taxpayers," CAPT Nelson said. "It 



"will be a good thing because of the 
increased opportunity that [service 
wives] will have to have their hus- 
bands ashore." Likewise, VADM 
Watkins said he believes "bringing 
women into the Navy will one day 
mature the male in the Navy and 
make him not only a better service- 
man but also a better citizen and a 
more all-round individual — one that 
will be more balanced and more ac- 
cepted by society." 

Often old myths are reflected in 
research assumptions. One exam- 
ple, reported by Joseph Ward, 
Ph.D., was a proposed Army Re- 
search Institute project to look at 
the effect of women on unit per- 
formance "degradation." In other 
words, there was an implicit as- 
sumption in the statement of the 
problem presented for study that 



Volume 69, March 1978 



1! 



performance would decrease as 
more women were added to the 
unit. Dr. Ward reported that, con- 
trary to the implicit assumption, 
actual research results showed no 
degradation in unit performance. 

Research can supply answers for 
many questions: What effect do 
women leaders have on other 
women and on men? What types of 
attitudes do men display? How do 
women leaders affect the work en- 
vironment? What intervention strat- 
egies help prevent degradation of 
unit performance and family dis- 
satisfaction? 

Payoffs in the form of increased 
operational effectiveness can also 
accrue from researching other than 
male/female dichotomies. For ex- 
ample, military missions could per- 
haps be performed more efficiently 
if we knew more about attitudinal 
factors in dichotomies such as offi- 
cer/enlisted, senior officer/junior 
officer, Black/White, and others. 

What are the correlations be- 
tween job satisfaction, perform- 
ance, retention, and various family 
factors? What is the relationship 
between leadership styles and fam- 
ily factors? ADM Zumwalt reviewed 
for conference attendees some of 
the steps he had taken as Chief of 
Naval Operations to improve reten- 
tion by reducing the length of family 
separations: finding more shore 
jobs for men with critical sea 
ratings; arranging overseas charter 
flights for dependents; establishing 
homeporting programs overseas; 
and creating exchange billets with 
foreign navies so more U.S. Navy 
members could be placed in excit- 
ing and challenging overseas areas. 
ADM Zumwalt cautioned, however, 
that answers which were appropri- 
ate yesterday may not be correct for 
tomorrow's questions. Evaluative 
research must be an ongoing proc- 
ess. 

STRESSFUL ENVIRONMENT 

Only in recent years have military 
decision-makers shown substantial 
interest in the military family. 
Nonetheless, as RADM Brown 



pointed out, "The more we study 
and learn about the military family, 
the better we will understand how 
the successful military family man- 
ages to coalesce the goals of the 
family with the goals of the military. 
. . . The military member's ability to 
function to capacity, to be happy in 
his role at work, and to grow in the 
military environment is dependent 
upon how well he or she and his or 
her family are able to integrate the 
family's goals with the military." 

The ever-present threat of family 
disruption through separation and 
the possibility of high-risk assign- 
ments and armed conflict create a 
constant environment of stress. 



ment of the military member, the 
actual deterrent and defense pos- 
ture of this nation is affected, then 
I'm going to get the money to do the 
research." 

The military organization is 
changing just as the family institu- 
tion — both in the military and in the 
civilian community — is changing. 
One important change is increasing 
numbers of married military per- 
sonnel, especially within enlisted 
ranks. BGEN Johns asked, "What 
are we going to do with all the bar- 
racks that we've built for soldiers to 
live in? We could probably convert 
them into apartment houses. We're 
spending hundreds of millions of 




Dr. Hunter and Dr. Nice brief press on conference 



What effect does so stressful an en- 
vironment have on families? What 
can be done to modify undesirable 
effects? According to VADM Wat- 
kins, "We need answers to a whole 
range of questions, and we are just 
beginning to learn what questions 
we should have been asking." 

BGEN Carr stated his firm belief 
that, "If we convince ourselves that 
there is a direct correlation between 
what happens to a family in a stress- 
ful environment such as this and the 
actual performance or productivity 
of the military member ... we can 
turn funding around and get it dis- 
tributed into areas where we des- 
perately need it — that is, into 
human behavioral research and pro- 
grams to meet the needs of our fam- 
ilies. . . . When I can convince a 
commanding officer and a Con- 
gressman that if they don't do 
something about the stress environ- 



dollars for barracks with rooms 
designed to accommodate three 
persons when we may find in the 
near future that we should have al- 
lowed for only one or two persons 
per room because most of the junior 
enlisted personnel are married and 
living in trailers." Also, research 
can perhaps solve some problems of 
married enlisted men and women 
who live day after day on the thresh- 
old of financial calamity. 

With changing policy we now 
have many single-parent families in 
the military — some headed by wom- 
en, some by men. Here, too, are 
questions which can be answered 
through research: Do we need dif- 
ferent support systems? For exam- 
ple, do we need 24-hour child care 
facilities? 

With changing societal norms 
and changing roles for both men 
and women come variations in mari- 



12 



U.S. Navy Medicine 



tal modes. We need to know more 
about the special problems of these 
nontraditional marriages and their 
relation to accomplishment of the 
military mission. We need to know 
how such marriages affect children. 
Is abuse more prevalent in the non- 
traditional family? 

Perhaps the major change in the 
traditional military family has been 
brought about by increasing num- 
bers of career servicewomen. With 
the servicewomen come new prob- 
lems: the impact of male/female at- 
titudes concerning women in non- 
traditional jobs; pregnant service 
personnel; families with "depend- 
ent" husbands; and problems 
unique to families in which the man 
and women both have military ca- 
reers — e.g., crises at reassignment 
and wives outranking husbands. 

Research already has shown that 
servicewomen lose less work time, 
have higher qualification scores, 
and cause fewer disciplinary prob- 
lems than men. But, according to 
BGEN Johns, "What we really 
should be looking at in research is 
the cultural aspect — the wide cul- 
tural differences between women 
and men." Professor Constantina 
Safilios-Rothschild, a consultant to 
the U.S. Coast Guard Academy, 
suggested that perhaps we should 
look at how men are integrated into 
a military organization which has 
career women service personnel, 
instead of vice versa. 

"Families experience an almost 
curvilinear path from high marital 
satisfaction at the beginning of 
marriage, but have no place to go 
but down for several years of the 
child-rearing period," reported Re- 
gents Professor Reuben Hill, cur- 
rently examining family life span 
development at the University of 
Utah. "What the family life span or 
career of military families looks like 
where they remain with the service 
over the life span would be fascinat- 
ing to bare, because many of the 
problems that are identified may 
actually be developmental problems 
rather than problems engendered 
by the military. That is, the military 
merely exacerbates but may not be 



responsible for many of the critical 
chaotic experiences of growing up 
with children and growing out and 
disengaging from one's spouse in 
the process." 

Military research can perhaps 
draw on such theories already de- 
veloped in the field of family re- 
search within the academic commu- 
nity. 

Whatever direction military fam- 
ily research takes, the need to trans- 
late research findings for clinicians 
and operations personnel remains 
constant. Furthermore, it was evi- 
dent from conference participants' 
comments that there must be a 
continual check between clinical as- 
sessment and empirical measure- 
ment to make certain that "good 
common sense" doesn't lead re- 
searchers in wrong directions or 
down blind alleys. 

CONCLUSIONS 

Presentations at the three-day 
Conference on Military Family Re- 
search showed that the factors 
which used to make the military 
community unique, such as pro- 
longed family separation and fre- 
quent moves, are becoming more 
apparent in the civilian sector, too. 
Conference attendees soon realized 
that studies of military families 
have wide applicability in the civil- 
ian community, and vice versa. 

Presentations also pointed up the 
fact that it is much more difficult for 
the military organization to compete 
with the family than it has been in 
the past. Thus, there is a greater 
need for research to delineate how 
the family can be made to function 
more effectively in support of the 
military organization. At the same 
time, we must discover how the 
military can contribute to the family 
"mission." A balance must be 
achieved between health-care de- 
livery services and other family sup- 
port programs and military family 
research. 

Many questions about the chang- 
ing times and the changing military 
were raised. One example: Do the 
new marriage relationships (com- 



mitted, whether legalized or not) 
which emphasize family loyalty and 
expectations of interpersonal close- 
ness sustain rather than threaten 
military functioning? Research can 
perhaps give us the answer. 

Although military family research 
has become a valid area of study, 
ADM Zumwalt cautioned that re- 
search must be repeated and on- 
going in order to measure the im- 
pact of changing times and environ- 
ments on the Navy family. We can- 
not otherwise know whether the 
solutions of the 1970's are applica- 
ble to the 1980's with regard to spe- 
cific programs or policies. Today, 
attitudes towards the family as an 
institution are ambivalent both in 
civilian and military settings; it has 
not yet been decided whether the 
family is an invaluable morale agent 
well worth the expenditures and 
emotional support it needs to sur- 
vive. 

Among the many recommenda- 
tions resulting from the conference 
were: 

• Develop a better system for ac- 
cessing reports based on military 
family research. Such a system 
would enable research findings to 
reach the people who can make 
practical use of the new informa- 
tion. One suggestion: a continually 
updated computerized bibliography 
of military family research publica- 
tions. 

• Increase liaison between military 
and civilian communities and be- 
tween researchers and caregivers. 
Thus, a second Conference on Mili- 
tary Family Research should be 
held in two or three years. Perhaps 
a conference devoted to health care 
services essential to meet families' 
needs could be held in the interim. 

• Improve dissemination of re- 
search results through a tri-service 
military family research journal or 
newsletter. 

• Encourage tri-service efforts in 
military family research to prevent 
duplication. Establishment of a 
Center for the Study of the Military 
Family, with staff and funding pro- 
vided by all three military services, 
should be considered. 



Volume 69, March 1978 



13 



Reserve 



New Wrinkle 

for Reserve Training 



Time was when Naval Reservists 
ot G-5 Mobile Hospital 118 could 
look forward to spending their ac- 
tive duty for training period learn- 
ing how to augment their regular 
medical counterparts. 

Not any more. 

As part of a new concept in the 
use of Reserve medical forces, the 
G-5 hospital unit is now designed 
for stand alone capability and 
assignment to Marine field opera- 
tions in the event of mobilization. 

For unit members this new wrin- 
kle in Reserve use meant wrinkles 
in brows and clothes, too. Not only 
would ACDUTRA now be spent 
learning new medical support pro- 
cedures, but members would also 
take to the fields for overnight exer- 
cises. 

March in step. The unit cruise 
was held last year at Marine Corps 
Base, Quant ico, Va. There mem- 
bers joined in parts of Marine train- 
ing and worked in Naval Hospital 
Quantico and its outlying clinics at 
Mann Hall, Marine Officer Candi- 
date School, and Camp Upshur. 

At Camp Upshur, unit members 
observed platoon leaders class 



training exercises and discussed the 
medical requirements attendant to 
such training. Then it was off on an 
overnighter. Reserve nurses, too, 
with packs on back, rode the heli- 
copters and field ambulances and 
marched in step with the rest of the 
unit. 

In the more familiar territory of 
the hospital and clinic, unit mem- 
bers conducted sick call and helped 
process physical examinations for 
officer candidate programs. Nurses 
received training at the hospital and 
rotated through the various nursing 
services. 

The G-5 Mobile Hospital 118 was 
formed in March 1977. It is attached 
to Readiness Command Region 18 
and is part of the U.S. Naval and 
Marine Corps Training Center in St. 
Louis, Mo. Commanding officer is 
CAPT George A. Brennan (MC). 

The two-week tour at Quantico 
gave unit officers a chance to meet 
with representatives from the Bu- 
reau of Medicine and Surgery, and 
the Marine Corps. These meetings 
helped to refine the concept of 
Marine Corps support and to deter- 
mine the course of future training. 



—Story submitted by LCOR Larry 
Peery, MSC, USNR-R. Photographs by 
LCDR Clyde Miener, MSC, USNR-R. 




HM1 Berry gets mosquito trap duty 




H 



LT Pat Wilson doesn't miss a step heading for 

U.S. Navy Medicine 




helicopter at Camp Upshur 

Volume 69, March 1978 



Reserve duty means training in hospital and ambulance 



15 



Scholars' Scuttlebutt 

Summer's Coming 
(and so is ACDUTRA) 

This article has been written primarily for students in the Armed Forces 
Health Professions Scholarship Program (AFHPSP), but much of the infor- 
mation concerning travel and per diem applies to all Navy students on 
funded active duty for training (ACDUTRA) orders. We hope, through this 
article, to offer you some insight into ACDUTRA travel and monetary poli- 
cies, although we realize we cannot address all situations you may run into 
while on ACDUTRA. Remember, the monetary amounts we cite are ap- 
proximate, and travel regulations continually change. Any conflict between 
the information in this article and local command payment policies is re- 
solved by the command's policies. 



Students in the Armed Forces 
Health Professions Scholarship 
Program must perform 45 days" 
ACDUTRA in paygrade 0-1 each 
year. ACDUTRA involves budget- 
ary funding and is partially con- 
trolled by the federal fiscal year (1 
October-30 September). You may 
not receive more than one ACDU- 
TRA period during one fiscal year. 
After you receive your ACDUTRA 
orders, follow all directions care- 
fully. You must report to the 
address (or addresses) shown on or 
before the specified times and 
dates. Your 45 days of ACDUTRA 
includes travel time. Authorized 
travel time may not exceed 24 hours 
at the beginning and at the end of 
the ACDUTRA period. If you live 
farther than normal commuting 
distance from your ACDUTRA duty 
station, the day before your report- 
ing date is counted as a day of 
travel, as is the day of detachment. 
If you receive orders to a duty sta- 
tion that is more than one day's 
driving distance from where you 
live, you should use commercial air 
transportation unless you wish to 
travel on your own time. If you do 
elect to travel on your own time, you 
are not considered to be on active 
duty more than 24 hours before the 
reporting time specified in your 



orders and 24 hours after the time 
you are detached. Thus you are not 
protected under active-duty medi- 
cal, death, or insurance benefits. 

If you are reporting to Officer In- 
doctrination School in Newport, you 
will not be able to travel on your 
own time since you will be ordered 
to an intermediate command — as 
explained later in this article. 

Your ACDUTRA orders will cite 
the amount of money set aside for 
pay, travel, per diem, and uniform 
allowances. The amounts shown for 
travel and per diem are maximum 
estimates. You will only be reim- 
bursed for whatever amounts are 
supported by the travel claim you 
submit when you report to your duty 
station. This reimbursement will 
vary depending on how you travel, 
how far you travel, and the avail- 



ability of government messing and 
berthing facilities. If bachelor offi- 
cers' quarters (BOQ) are available, 
you must either use them or secure 
lodging at your own expense. You 
are expected to make BOQ reserva- 
tions approximately four weeks in 
advance, by writing to the BOQ 
officer of the command to which you 
are ordered. 

The amount for pay cited in your 
orders includes basic allowance for 
quarters (BAQ) and subsistence. 
BAO at the 0-1 level is $193.80 a 
month for married officers, and 
$148.80 a month for single officers. 
Subsistence amounts to $59.53 a 
month for all personnel. Single offi- 
cers lose their basic allowance for 
quarters if they reside in the BOQ, 
but they still receive a "partial 
rate" of $13.20 per month. Married 
officers do not lose their basic allow- 
ance if they reside in the BOQ. 

The following information should 
help you plan your expenses: 

• If you travel by private automo- 
bile you will receive 74 per mile, if 
you also receive per diem. But you 
will receive per diem only if no 
government quarters and/or no 
government messing is available. 
You will receive 10 i per mile if 
both government quarters and 
messing are available. Travel miles 
are based on official government 
distance tables. There is no reim- 
bursement for meals when you 
travel by private automobile. 

• If you travel by commercial trans- 
portation, save all air, train, bus, 
and taxi receipts to support your 
claim. An allowance will be paid for 
the meals you take while you are 
traveling commercially. There's no 




Government berthing is always available at Officer Indoctrination School, Newport 



16 



U.S. Navy Medicine 



necessity to save meal receipts. 

• If both government messing and 
berthing are available, you will 
receive no per diem reimburse- 
ment, even though there will be a 
daily BOQ service charge at most 
duty stations. The BOQ service 
charge varies since it is set by each 
command. It has been known to 
range from SI. 50 to $2.50 a day, but 
could go higher. 

• Government messing and berth- 
ing are always available for students 
at OIS, and at this command only 
there is no BOQ service charge. If 
you are not drawing per diem, 
Navy-wide government messing will 
cost about 95c for breakfast, $1.50 
for the noon meal, and $1.50 for the 
evening meal. Meal rates are higher 
if you are drawing per diem. 

• You must reside in the BOQ if 
space is available. However, if 
neither government berthing nor 
messing is available, you will 
receive approximately $16 a day for 
meals. Be sure to save your 
itemized lodging receipts. Per diem 
reimbursement for meals and lodg- 
ing together usually cannot exceed 
$35, although in a few designated 
areas the amount is higher. In the 
Washington, D.C., area, for exam- 
ple, the limit is $50. 

• If government messing but not 
berthing is available, you will usual- 
ly receive $9.85 a day plus the aver- 
age cost of your lodging. 

• If government berthing but not 
messing is available, you will re- 
ceive approximately $16 a day for 
meals. Also, in this situation only, 
you will be reimbursed for BOQ 
service charges, 

• If you are ordered to a duty sta- 
tion within commuting distance 
from your home, you will receive no 
travel allowance and no per diem. 

• The time at which you are paid 
your travel allowance and per diem 
will vary from one duty station to 
another. While travel will probably 
not be paid until you return home, a 
portion of per diem is sometimes 
advanced when you report aboard, 
especially if you must secure com- 
mercial lodging. The initial uniform 
allowance is paid within two to three 



weeks after you report to OIS at 
Newport, but not until well after you 
complete ACDUTRA at any other 
duty station. 

If you are ordered to OIS and live 
so far away that you cannot travel 
there by private conveyance within 
24 hours, travel by commercial air 
transportation will be necessary. 
You are cautioned against trying to 
drive excessively long distances 
that could jeopardize your safe and 
punctual arrival. 

Before you report to Newport you 
must first be ordered to a Naval Re- 
serve Center near your home for 
three days, since the Newport train- 
ing lasts only 40 days and school 
officials will not allow early report- 
ing. You must physically report to 
and leave from this "intermediate" 
Naval Reserve Center duty station 
at the time and date stated in your 
orders. Officials at the Center will 
endorse your orders when you 
arrive and when you depart. Be- 
cause of this policy, many of you 
will find there is no way you can 
travel to Newport on your own time, 
and you will have to use commercial 
air travel, like it or not. 



While on ACDUTRA you are en- 
titled to active-duty medical bene- 
fits and to Servicemen's Group Life 
Insurance (SGLI) of $20,000, for 
which $3.40 a month will be auto- 
matically deducted from your 
ACDUTRA pay along with federal 
income tax and FICA (Social Secu- 
rity) withholding. 

The medical benefits have broad 
implications. One of the benefits 
concerns dependent care under the 
Civilian Health and Medical Pro- 
gram of the Uniformed Services 
(CHAMPUS). You should be aware 
that the Naval Health Sciences Edu- 
cation and Training Command will 
not force ACDUTRA orders to coin- 
cide with elective or planned hos- 
pitalization of dependents — includ- 
ing maternity care benefits under 
CHAMPUS. 

ACDUTRA is assigned during 
summer vacation break periods 
whenever possible. You will receive 
your orders approximately 30 to 60 
days before your reporting date. To 
be on the safe side, don't make any 
plans for your vacation months until 
you have the exact dates of your 
active duty for training. 



Where Are the Ensigns? 



Which school has the greatest 
number of Navy-sponsored students 
in the health professions? It's 
Georgetown University in Wash- 
ington, D.C., with a total of 81. 
Navy-sponsored medical, dental 
and Medical Service Corps students 
are also in evidence at the following 
schools: 

University of Tennessee 

Virginia Commonwealth University 

University of Miami 

George Washington University 

Indiana University 

University of Pittsburgh 

Ohio State University 

Georgia School of Medicine 

St. Louis University 

University of Pennsylvania 

Emory University 

Tufts University 

University of Maryland 

University of Washington 



University of Alabama 

University of Iowa 

University of Texas. San Antonio 

Temple University 

University of Virginia 

Medical University of South Carolina 

Tulane University 

Case Western Reserve University 

Creighton University 

Jefferson Medical College, Philadelphia, Pa. 

University of Florida, Gainesville 

New Jersey College of Medicine and Den- 
tistry 

Northwestern University Medical School 

University of Mississippi 

Boston University 

College of Osteopathic Medicine and Sur- 
gery, Des Moines. Iowa 

Louisiana State University, New Orleans 

Meharry Medical College School of Medi- 
cine, Nashville, Tenn. 

New York Medical College. N.Y.C. 

University of Illinois 

University of Southern Florida 

University of Southern California, Los An- 
geles 



Volume 69, March 1978 



17 



Policy 



Instructions and Directives 



Nonavailability statements 

All naval medical facilities with inpatient capability 
should continue submitting monthly reports to BUMED 
(Code 733) on the number of nonavailability statements 
(DD Form 1251) issued. Reporting procedures are set 
forth in BUMED Instruction 6322. 12A of 15 Nov 1977. 

Dispensing prescription spectacles 

Prescription spectacles sometimes are not delivered 
to the patient for whom they were ordered because of 
administrative error, transfer or separation of the pa- 
tient, or other reasons. Patients may then have to order 
duplicate spectacles and undergo a repeat visual exam. 

To avoid this waste of time and materials, Navy 
clinics shall deliver daily spectacle orders to optical 
laboratories or service units. Clinics and laboratories 
shall use the fastest means to deliver spectacles. 

Clinics shall dispense spectacles promptly to pa- 
tients. If a patient has been transferred, spectacles 
shall be forwarded immediately to the new duty station. 
Spectacles that cannot be delivered should be returned 
to the servicing optical laboratory or service unit along 
with DD Form 771/771-1 and a statement explaining 
why they are being returned. — BUMED Notice 6810 of 
16 Nov 1977. 

Daily Dental Service Record 

A revised individual dental officer data collection 
record (NAVMED 6620/1) has been developed. The 
new standardized form will document information 
about the number of dental procedures provided by 
each dental officer and other dental health care pro- 
viders. The NAVMED 6620/1 will become the basis for 
a historical record of all patients treated within a dental 
facility. 

The revised forms shall be used at all Navy dental 
treatment facilities and shall be completed daily by 
each dental health care provider. Completed forms 
shall be retained at the facility for at least two years. 
Data collected shall be used to prepare quarterly dental 
service reports.— BUMED Notice 6620 of 28 Nov 1977. 

Uncollectible accounts 

The number of accounts receivable being written off 
at naval medical facilities or referred to BUMED for 
further collection action is increasing. Medical facilities 
must take immediate action to strengthen procedures 
for collecting these accounts and minimizing writeoffs. 
Specifically, existing procedures will be reviewed to 



ensure compliance with the Financial Management 
Handbook (NAVMED P-5020). 

Payment in full shall be requested from pay patients 
on the day they are discharged. If payment is not re- 
ceived, the patient or sponsor will be given a statement 
of charges. Arrangements can be made for monthly 
payments, particularly when large amounts are due. If 
such payments are not made, courteous but increasing- 
ly forceful correspondence shall be sent at 30-, 60-, and 
90-day intervals with the objective of securing the un- 
paid amount. 

By far the largest dollar amount of accounts written 
off as uncollectible are those of CHN1 (civilian humani- 
tarian nonindigent) patients who are charged the full 
rate of $206 a day. CHNI patients not covered by insur- 
ance usually have no way to pay their bill and the 
charges are eventually written off after collection ef- 
forts prove futile. 

A patient's eligibility for medical care should be de- 
termined promptly. Patients who claim but cannot 
prove eligibility should be admitted but should be re- 
quired to sign a certification of eligibility and informed 
that proper proof of eligibility must be provided by the 
second working day after their admission. Patients who 
refuse to sign such certification will be denied admis- 
sion except in emergencies. 

Patients determined to be ineligible for government- 
sponsored care shall be informed immediately that 
their status is changed to CHNI and that they will be 
required to pay the full reimbursable rate. The number 
of CHNI sick days at a Navy facility will be minimized 
by discharging or transferring such patients to other 
hospitals as soon as their condition permits. 

U.S. citizen civilian government employees at over- 
seas activities are now charged the full reimbursable 
rate for hospitalization. While most of these patients 
depend on insurance carriers to cover their bills, the in- 
surance companies routinely review hospital admis- 
sions and refuse to pay when inpatient care was obvi- 
ously not warranted. When the hospital bill is large, 
patients usually await settlement of their claim before 
remitting payment; if the insurance settlement is sub- 
sequently denied, the account is very likely to be uncol- 
lectible. Therefore, the need for admission must be 
thoroughly considered before a U.S. employee or the 
dependent of such an employee enters the hospital. If 
good medical practice dictates that the problem can be 
handled on an outpatient basis, the patient should not 
be admitted. 

When a dependent's hospital stay will be prolonged, 
the sponsor should be contacted and tactfully informed 
that periodic payments can be made during the period 
of hospitalization. Also, every pay patient should be in- 
formed in writing exactly what the per diem charges 
will be. Reading and signing such notification should be 
part of the admission routine. The signed notification 
should then be forwarded to the collection agent. — BU- 
MED Notice 6322 of 2 Dec 1977. 



18 



U.S. Navy Medicine 




LCDR Alvarez: Worth waiting for 



NAVMED Newsmakers 



LCDR Rosa Alvarez (MC) knows 
anything worth having is worth 
waiting for. But even she, when she 
applied in 1963 to leave her native 
Cuba, couldn't imagine it would 
take eight years to receive permis- 
sion. In the meantime she set up a 
private pediatric practice in Havana 
and perfected the English she 
began learning in grade school. 
Admitted to the U.S. in 1971, she 
successfully completed the written 
test required of all foreign-trained 
physicians and went on to become 
board-qualified in pediatrics. "I 
could have established my own 
practice," Dr. Alvarez says, "but I 
felt I owed the U.S. more. This 
country has done so much for my 
family. I felt a need to repay Amer- 
ica's kindness and hospitality. It 
seemed to me that the country 
needed doctors more in the military 
than they did in private practice, so 
1 applied for a commission in the 
Navy and was accepted." Dr. 
Alvarez now brings an international 
touch to the branch clinic at 
Mayport Naval Station, Fla. 

"This is something I always 
wanted to do," HM3 Ivary Hopkins 
says of his work as a medical labora- 
tory technician at NRMC San Diego. 
But there were plenty of detours. 
After high school, HM3 Hopkins 




HM3 Hopkins: Good feeling 

worked on the wards of Lafayette 
(La.) Charity Hospital before joining 
the Navy in 1972. He hoped for a 
career in health care, but instead 
was assigned as a deck seaman. "I 
must have put in a request chit 
every week asking to go to Hospital 
Corps School," he remembers. 
"Eventually 1 had an interview with 
a physician who recognized my po- 
tential and helped me get accepted 
at the School." After his training, 
he spent a year in general hospital 
corpsman duties before moving into 
the medical laboratory technician 
specialty. Now, in support of the 
Pacific Fleet, he spends hours each 




CAPT Ballard wears 1918 uniform 

day searching out abnormalities in 
blood and urine samples. "We 
come across mononucleosis and 
hepatitis often," he says, "but it 
really gives you a good feeling to 
spot something like leukemia and 
know that your early detection may 
help save a sailor's life." 

CAPT Gerald Ballard (DC) is 

looking for a pearl-handled dental 
instrument kit — the kind his great- 
great-grandfather might have used, 
if his great-great-grandfather had 
been a dentist. Purpose of search: 
to add this treasure from the 1820- 
1850 era of dentistry to a growing 
collection that includes an 1893 foot- 
powered dental drill, a turn -of -the - 
century dental console with marble 
front, and a 1918 Dental Corps uni- 
form. Finding room for all this in 
the Ballard home isn't easy. The 
captain fears the day he will have to 
take his 1770 naval cutlass out of its 
leather case and do battle with son 
Brian's encroaching collection of old 
fire arms, helmets, swords, dag- 
gers, and gas masks. 



Volume 69, March 1978 



19 



Notes & Announcements 



CONTINUING EDUCATION FOR NAVY NURSES 

The Naval Health Sciences Education and Training 
Command will sponsor the following continuing educa- 
tion course for Navy nurses: 

Problem Oriented Records and Nursing Audit (18 contact hours) 
5-7 June 1978 New London, Conn. 



Participants will learn the components of the problem- 
oriented system and the basic principles of problem- 
oriented medical records and audit. Practice will be 
given in developing problem lists, writing progress 
notes in the 'SOAP' format, and applying principles of 
audit using the problem-oriented system. 

The course is open to Nurse Corps officers not cur- 
rently assigned to an oversea billet. However, nurses 
assigned to Argentia, Newfoundland; Bermuda; Guan- 
tanamo Bay, Cuba; Keflavik, Iceland; and Roosevelt 
Roads, Puerto Rico, who have served at least six 
months on active duty, may apply. The course is also 
open on a space-available basis to Nurse Corps officers 
of the inactive Reserve. 

Nurse Corps officers wishing to attend the course 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval Medi- 
cal Center, Bethesda, Md. 20014, following procedures 
set forth in the BUMED Instruction 1520.8 series. Ap- 
plications should be submitted several weeks before a 
course begins. 



AFIP'S ANNUAL LECTURES 
SCHEDULED FOR JUNE 

The 18th Annual Lectures sponsored by the Armed 
Forces Institute of Pathology (AFIP) will be held 5-9 
June 1978, at the Sheraton Motor Hotel, Silver Spring, 
Md. 

Course content will center on a review of recent 
advances and information in anatomic pathology (and 
clinical pathologic methods as they apply to pathology) 
involving the various organs and body systems. Topics 
include common pitfalls in diagnosis; review of unusual 
cases and statistical data; review of articles published 
by staff members; new advances in histochemical, 
bacteriological, biochemical, immunological, and toxi- 
cological methods in the daily practices of pathology. 

Applicants should be members of the Medical Corps 
of the Armed Forces or other Federal services who are 
board eligible or certified in pathology. Applications 
from qualified civilians will be considered on a space- 
available basis. Requests for course reservation should 
be received by the AFIP on or before 8 May 1978. 
Please include the following information: (1) Name, 
address, and country, if foreign; (2) Federal or civilian 



organization; (3) Position held; (4) Professional board 
status, certified or eligible; (5) Degree in specialty; and 
(5) Military rank. Those wishing to attend should write 
to the Director, Armed Forces Institute of Pathology, 
ATTN: AFIP-EDZ, Washington, D.C. 20306. 

DENTAL OFFICERS SELECTED FOR 
ADVANCED TRAINING 

Forty-four dental officers were selected for residency 
training in FY78/79. The selectees are listed under 
training locations. 

National Naval Dental Center, Bethesda, Md. 

Comprehensive Dentistry {first year): CDR Robert L. 
Jucovics; LCDRs Paul L. Auclair, David R. Fitch, 
Courtney C. Lamb, Vincent M. Lynch, George R. 
Myers, and Richard F. Sobie; LTs Benjamin S. Antio- 
quia, William J. Boyd, George W. Freeman, Charles F. 
Massler, and Thomas F. Starck. 

Comprehensive Dentistry (second year); LCDRs 
Melvin L. Davis, John W. Hargrave, Raymond J. Kielt, 
Mark J. Mailander, and John J. Rizas; LT James T. 
Judkins. 

Endodontics: LCDRs John J. Boyd, Thomas J. Boyer, 
and Randolph M. Stevens. 

Oral Medicine: LCDR Walton A. Rathbun, Jr, 

Periodontics: LTs Douglas E. Mitchell, George 
Quintero, and John E. Trapp. 

Prosthodontics: LCDRs John D. Schroeder, Edward 
M. Fraleigh, James W. Taylor, Robert B. Linville, and 
Jerry E. Morley; LT Gerald J. Barna. 

Maxillofacial Prosthetics: CDR James J. Shanley, 

Oral Pathology: LCDR Gary R. Warnock. 

Naval Regional Medical Centers 

Oral Surgery: LCDRs Michael J. Kelley, Richard P. 
Rog, Timothy S. Smith, and Charles B. Stuller; LTs 
Jeffrey A. Lane and Michael P. Mullen 

Advanced Training at Civilian Universities 

Endodontics: LCDR Joseph W. Lehman III. 
Operative: LCDR Michael T. Hanst. 
Periodontics: LCDR John Common. 
Prosthodontics: LCDRs Arthur S. Daley, Jr., and 
Robert L. Duell. 



I 'TO j B 



20 



U.S. Navy Medicine 



Features 



Navy Flight Surgeons: 
From Biplanes to Skylab 



Jacquelynne M. Devine 



Navy aviation medicine got its 
start on 8 Nov 1921, when five Navy 
medical officers were ordered to re- 
port to the Army School for Flight 
Surgeons at Mitchell Field, Long 
Island, N.Y, 

The school, established in May 
1919 as the Army's Central Re- 
search Laboratory, offered the first 
formal course in the new discipline: 
aviation medicine. 

Those naval pioneers were LTs 
Victor S. Armstrong, Louis Iverson, 
Julius F. Neuberger, Page O. 
Northington, and Carl J. Robertson. 
Their class graduated on 29 April 
1922. One year later, Dr. Armstrong 
was ordered to the Bureau of Medi- 
cine and Surgery to become the first 
chief of the Aviation Medicine Divi- 
sion. 

Even with its own division avia- 
tion medicine was still a fledgling, 
as was all of naval aviation. Flight 
surgeons of the 1920's and 1930's 
often had duty at other than aviation 
facilities. Flight pay was allocated 
to aviation units, and the com- 
manding officer decided whether to 
authorize flight pay for individual 
flight surgeons. 

Navy flight surgeons trained with 
the Army at Mitchell Field until 
1926. When the Army moved its 
school to Brooks Field, Tex., that 
year, the Navy seemed to lose inter- 
est in training flight surgeons: only 
25 such officers were trained be- 
tween 1926 and 1935. 

During these years a curriculum 
for flight surgeons was established 



Jacquelynne Devine is public information 
specialist at the Naval Aerospace Medical 
Institute, Pensacola, Fla. 32508. 



at the Naval School of Medicine in 
Washington, D.C. One class of 
eight students graduated on 29 
April 1927. Records indicate, how- 
ever, that no more flight surgeons 
were trained for the next three 
years. 

Commodore Wilbur E. Kellum, 
now retired, remembers what it was 
like to train as a naval flight surgeon 
in those early days: 

"While I was attending the Naval 
Medical School in 1931, I expressed 
an interest in aviation medicine. 



struction in land planes at Corry 
Field. By that time an individual 
was usually considered qualified to 
fly solo, but we were not permitted 
that bit." 

Dr. Kellum, who is credited 
with designing a prototype of the 
oxygen mask, provides us with the 
first evidence of flight training as 
part of the flight surgeon curricu- 
lum. But he was not the first Navy 
medical officer to fly. LT Bertram 
Groesbeck, Jr., had been ordered to 
flight training in 1921. He was des- 




Navy members of first class of flight surgeons, shown here with friends and instruc- 
tors, were (top row): LTs Iverson and Robertson (3rd & 4th from left); LTs Arm- 
strong and Northington (7th & 8th from left); and LT Neuberger (3rd from right) 



One of the staff members, Joel 
White, who had completed the 
Army's course in 1925, told me that 
if I wanted to stay on in Washington 
I could use his notes from school. 

"I reported to the Naval Air Sta- 
tion, Pensacola, for indoctrinal 
flight training on the 26th of Sep- 
tember. 1931. This consisted often 
hours of dual instruction in training 
planes on floats. We flew around 
and around Pensacola Bay practic- 
ing landings on the water. This was 
followed by ten hours of dual in- 



ignated a naval aviator in 1922 and 
immediately reported to Mitchell 
Field for training as a flight sur- 
geon. 

During the late 1920's and 1930's 
there was pressure on the Bureau of 
Medicine and Surgery to establish a 
permanent Navy school for flight 
surgeons. Principal proponents of 
the Navy training were two medical 
officers: CAPT J.C. Adams and 
CAPT Frederick Ceres. 

CAPT Adams, a graduate of the 
second Navy class at Mitchell Field, 



Volume 69, March 1978 



21 



was head of the Aviation Medicine 
Division; CAPT Ceres, a graduate 
of the third class, was medical offi- 
cer for Naval Air Station, Pensacola. 
While the Navy wouldn't go along 
with establishing its own school, it 
did begin again to send Navy medi- 
cal officers to the Army's school — 
by then located at Randolph Field, 
Tex. An additional 20 Navy physi- 
cians trained there between 1935 
and 1939, reporting afterwards to 
Pensacola for six months of flight 
training and training with other 
qualified flight surgeons. 

A SCHOOL OF THEIR OWN 

On 8 Nov 1939, President Frank- 
lin D. Roosevelt declared a limited 
state of emergency, and the medical 
department at Pensacola was told to 
establish a curriculum for aviation 
medical examiners. Twelve days 
later, nine Reserve medical officers 
reported for training. CAPT Ceres 
was given responsibility for organiz- 
ing a training course and adminis- 
tering the program. A manual was 
hurriedly put together from notes 
kept by flight surgeons who had 
completed the Army course. 

Classes were first held in one 
room of the Pensacola Naval Dis- 
pensary. In December, the medical 
department and the new School of 
Aviation Medicine moved into new 
but cramped quarters in a building 
whose plans had been drawn up 
long before space for a school be- 
came a consideration. That building 
still stands, its many additions at- 
testing to the accommodations 
made to support the Navy School of 
Aviation Medicine. 

But the Navy still had not ac- 
cepted the concept of training naval 
flight surgeons. Emphasis was on 
the need for administering flight 
physical examinations, and the first 
graduates of the school were desig- 
nated aviation medical examiners. 
The 60- day program offered instruc- 
tion in cardiovascular disease, 
neuropsychiatry, general physical 
examination, dental examination, 
and eye, ear, nose and throat dis- 
ease. 




Naval Air Station Pensacola In 1940s. Dispensary Is in foreground; Naval School of 
Aviation Medicine in background 



Anselm C. Hohn, LT Julian Jordan, 
and CAPT Alfred W. Chandler, a 
Dental Corps officer. 

In July 1940, five regular Navy 
medical officers were ordered to the 
school to be trained as naval flight 
surgeons. Training included the 60- 
day didactic program with a Reserve 
class, plus a 60-day ground school 
and flight indoctrination phase. A 
third phase consisted of six weeks' 
additional duty at outlying fields 
and aviation examining rooms, 
working under the direction of more 
experienced flight surgeons. 

The first class of flight surgeons 
graduated from the Navy School of 
Aviation Medicine on 30 Nov 1940. 

RESEARCH AND DEVELOPMENT 

In 1940, the immediate problems 
of aviation medicine involved medi- 
cal research and pilot selection. To 
help in these areas, the school 
established a department of re- 
search, with a staff of some of the 
finest scientists from the civilian 
community. A good number of 
these civilians came on active duty 
during World War II and made sig- 




Navy flight surgeon and flight nurse 
check on patient before hospital plane 

takeoff (Feb 1945) 

Although CAPT Ceres had been 
ordered to establish the school, he 
was not authorized additional staff 
members. The first faculty there- 
fore was made up of CAPT Ceres, 
CDR Victor S. Armstrong, CDR 
Frank E. Tierney, LCDR William 
W. Davies, LCDR Rex H. White, 
LCDR Wilbur E. Kellum, LCDR 



22 



U.S. Navy Medicine 



nificant contributions in the field of 
aerospace medicine. Notable among 
these researchers were Drs. Ross 
McFarland, Eric J. Liljencrantz, 
Joseph L. Lilienthal, and Ashton 
Graybiel. 

Dr. McFarland, from Harvard 
University, pioneered the medical 
support of Pan American Airways 
and did much physiological research 
into the effects of altitude as well as 
work in pilot selection criteria. He 
was commissioned in the Naval 
Reserve and was a member of the 
Harvard study group that conducted 
the famous Thousand Aviator 
Study. He wrote the classic text, 
Human Factors in Air Transporta- 
tion, published in 1953. 

Dr. Liljencrantz, who had been 
head of Pan American's medical 
facility in San Francisco, came on 
active duty as a lieutenant com- 
mander to continue his research 
work. He was killed on 5 Nov 1942 
near NAS Pensacola while engaged 
in an experimental research flight. 

Dr. Lilienthal joined the staff 
from the Johns Hopkins University 
School of Medicine and worked on 
the effects of reduced barometric 
pressure, carbon monoxide, and 
airsickness, as well as selection 
criteria for aviators. 

Dr. Graybiel over the years be- 
came involved with almost every 
aspect of research. He was director 
of research after World War II and 
retired as a Navy captain. Following 
his retirement from active duty, Dr. 
Graybiel continued working in med- 
ical research and is today on the 
staff of the Naval Aerospace Medi- 
cal Research Laboratory — a direct 
descendant of the original School of 
Aviation Medicine. 

WORLD WAR II 

With the onset of World War II, 
the training program was accel- 
erated and classes convened more 
frequently. The well-trained flight 
surgeon was proving to be indispen- 
sable in keeping fliers healthy and 
fit to perform their duties. 

The school curriculum began to 
emphasize support of operational 



units. The original concept of 
creating aviation medical examiners 
for cadet selection boards had 
stressed physical examination and 
selection. Now the emphasis moved 
to operational aviation medicine, 
maintenance of pilot health, surviv- 
al, air evacuation, and many other 
important areas. 

In the opening phases of World 
War II, the school had a staff of 15 
officers. Subjects taught were: avia- 
tion history, aviation medicine, 
dental lectures and demonstrations, 
Navy regulations and customs. 



tional unit after graduation from the 
School of Aviation Medicine, ac- 
cumulate 60 hours of flying time, 
and be recommended by their 
senior medical officer. Most of the 
students who graduated as aviation 
medical examiners were redesig- 
nated flight surgeons by the end of 
the war. 

Then, on 18 May 1942, the Chief 
of Naval Personnel authorized the 
first flight surgeon insignia. It was 
to be worn "on the left breast by 
officers of the Medical Corps who 
qualified as naval flight surgeons." 




Staff members at Naval School of Aviation Medicine test a volunteer for coronary 
insufficiency (March 1949) 



ophthalmology, otolaryngology, 
normal psychology and personality 
study, psychoneuroses and psycho- 
ses, physiology, cardiology, aviation 
physical examinations, physiologi- 
cal optics, psychological tests and 
testing, administration, and service 
customs and courtesies. Flight sur- 
geons were even taught to march. 

By 1942 the naval flight surgeon 
had become an integral member of 
the aviation community and had 
begun to get special recognition. 
First, provisions were made for 
aviation medical examiners to 
change their designation to naval 
flight surgeon. To do so they had to 
complete six months with an opera- 



The insignia was a winged metal pin 
with an ovoid central device sur- 
charged with the gold leaf and silver 
acorn insignia of the Navy Medical 
Corps. There was a fringe below the 
central device and three horizontal 
wing feathers were on each side. 

It was fitting that CAPT Ceres 
was the first to wear the new insig- 
nia. The wings were fashioned by 
the Dental Department and pre- 
sented to CAPT Ceres on 19 July 
1942 when he left the School of 
Aviation Medicine and the NAS 
Pensacola medical department. 

A third milestone was reached on 
10 Oct 1942. The Secretary of the 
Navy sent to the Chief, Bureau of 



Volume 69, March 1978 



■z:\ 



Supplies and Accounts, an amended 
definition of "nonflying officer." 
Navy flight surgeons were, for the 
first time, administratively included 
under the term "flying officers" 
and were entitled to draw flight pay 
while detailed to duty involving 
flying. 

Naval flight surgeons proved 
their worth and mettle during the 
war. More than 1,200 flight sur- 
geons were trained at the School of 
Aviation Medicine; 27 of them died 
in the line of duty. 

POST-WAR YEARS 

The post-war years were not 
growing years for Navy flight sur- 
geons. The first class to convene 
after hostilities ended had only 
seven students. Small classes were 
to be the rule rather than the ex- 
ception for another six years. 

On 15 Oct 1946, the school 
became a command. For the first 
seven years it had operated as an 
adjunct to the station's medical 
department, with no official status: 
now the school was a component of 
the Naval Air Basic Training Com- 
mand. 

In peacetime, many flight sur- 
geons left active duty. Only a hand- 
ful remained. 

The first jolt to this placid posture 
of "peace" came with the Berlin 
Crisis in 1948. LTJG Richard D. 
Nauman, later to be one of the few 
flight surgeons to attain flag rank, 
became intimately involved with the 
Berlin Crisis. Assigned as flight 
surgeon for the two Navy squadrons 
involved with "Operation Vittles," 
he participated in 25 missions. 

Less than two years later the 
peace was not just jostled but shat- 
tered. On 25 June 1950, North 
Korea invaded South Korea. Two 
days later President Harry S. 
Truman ordered U.S. forces to the 
support of South Korea. On 3 July 
1950, Air Group 5 from USS Valley 
Forge made the first air strikes. A 
new generation of flight surgeons 
was introduced to combat. 

Again, the School of Aviation 
Medicine went into full operation. 




Flight surgeon training In 1958 Included learning the fine points of eye examination 
under guidance of an instructor 



From classes of 6 or 7, the numbers 
swelled to 25 and more. Refresher 
courses were held for former flight 
surgeons recalled to active duty. 

The naval flight surgeon pro- 
gram, like other military training 
programs, was retained after the 
end of hostilities. The new watch- 
word was "readiness." 

In the midst of this growth, the 
school was again redesignated. No 
longer a component command with 
an officer in charge, the school be- 
came a command in its own right. 
CAPT Leon D. Carson made the 
transition from officer in charge to 
commanding officer on 9 July 1951. 

GROWTH 

In 1955, after several years of 
work by the Aeromedical Associa- 
tion, the American Medical Asso- 
ciation Committee on Medjcal Edu- 
cation, and the American Board of 
Preventive Medicine, a program 
was adopted by the American Board 
of Preventive Medicine which would 
lead to certification in the speciality 
of aviation medicine. Many senior 
naval flight surgeons were able to 
qualify without examination, while 



others qualified after examination. 
A formal program of advanced 
training was established at the 
School of Aviation Medicine, and 
the following year the curriculum 
was approved by the American 
Board of Preventive Medicine for 
two years' formal credit. 

On 19 Dec 1956, the Chief of 
Naval Air Training established the 
Special Board of Flight Surgeons. 
This permanent board of medical 
officers was appointed at the school 
to "provide prompt and highly com- 
petent professional review of the 
physical qualifications of aviation 
trainees and to expedite processing 
of those not qualified to continue 
training." The senior member of 
the board was the school's com- 
manding officer. 

In the 21 years since then, the 
Special Board of Flight Surgeons' 
scope has expanded to include not 
only aviators in training but also 
aviators already assigned to the 
fleet. The board reviews medical 
findings and makes recommenda- 
tions to the Bureau of Medicine and 
Surgery concerning the physical 
qualifications of all aviators who 
appear before it. 



24 



U.S. Navy Medicine 



THE SPACE AGE 

Some flight surgeons have held 
dual designations as flight surgeon 
and naval aviator. In 1975, two 
training billets annually were au- 
thorized for continuing this dual 
training. The best known flight sur- 
geon/naval aviator is astronaut 
CAPT Joseph P. Kerwin, a gradu- 
ate of flight surgeon class 89. 

Flight surgeons have made nota- 
ble contributions to aviation medical 
research. In the embryonic space 
age, staff members at the school 
designed a space capsule for pri- 
mates and trained primates for 
space shots. "Baker," the first pri- 
mate to survive a trip into space, 
was trained at the School of 
Aviation Medicine. 

New equipment and personnel 
were added to the school's research 
department during the 1950's and 
1960's, and many projects were 
funded by the newly formed Nation- 
al Aeronautics and Space Adminis- 
tration. 

LCDR Victor A. Prather, a naval 
flight surgeon, was the medical in- 
vestigator on Strato Lab No. 5, a 
Navy high-altitude balloon flight. 
On 4 May 1961, ascent was made to 
an altitude of more than 113,000 
feet — a new record. Tragically, 
LCDR Prather drowned during re- 
covery of the balloon. 

By September 1965, it would have 
been difficult for the graduates of 
flight surgeon class 1 to recognize 
their alma mater. No longer a one- 
room school house, the School of 
Aviation Medicine and its mission 
had expanded so dramatically that a 
new name was in order: it became 
the Naval Aerospace Medical Insti- 
tute. 

The Research Department was 
also advancing. On 19 Jan 1970, 
that department was redesignated a 
component command of NAM1 and 
renamed the Naval Aerospace Med- 
ical Research Laboratory. The labo- 
ratory became a separate command 
on 1 July 1974, with Navy flight 
surgeon CAPT Newton W. Allebach 
as first commanding officer. 

Throughout the Navy, change 





CAPT Kerwin, first physician in space, checks out bicycle ergometer 



was taking place. One significant 
change was in the status of military 
women. Not immune to these 
changes, the flight surgeon pro- 
gram on 21 March 1974 graduated 
its first female flight surgeons, LTs 
Jane McWilliams and Victoria 
Voge. 

Although the Navy recognizes the 
need for the special skills of naval 
flight surgeons, austere funding has 
limited the number available to the 
fleet. Aviation medical officers be- 
gan training at NAMI in 1975 to 
help offset the shortages of flight 
surgeons in critical areas. 

Also, a new breed of flight sur- 
geons is now joining the operational 
forces. In August 1976, the first two 
flight surgeon/family practitioners 
graduated from NAMI. LCDRs 
Leon J. Davis and Barry Mullen 
completed their family practice resi- 
dencies at the Naval Aerospace and 
Regional Medical Center in Pensa- 
cola, taking flight surgeon curricu- 
lum courses at NAMI during their 
final year. They were then ordered 
to flight training before being desig- 
nated naval flight surgeons and re- 
porting to their first operational 
billets. 

For a number of years, naval 
flight surgeons received flight in- 
doctrination in the T-34B "Men- 
tor." Transition to the T-34C and 
base realignment jeopardized the 
flight portion of the flight surgeon 



LT J. Gassier, MC (left), member of 
1975 "Blue Chip" class, checks flight 
plan with instructor 

curriculum in 1975. However, the 
commander of the Naval Air Train- 
ing Command recognized the im- 
portance of this indoctrination and 
in 1976 authorized flight training for 
flight surgeons in the T-2, after the 
"Blue Chippers" of Class 75-2 
proved it could be done. 

For more than half a century the 
naval flight surgeon has overcome 
obstacles to make contributions to 
aviation, aerospace, and the nation. 
This group of dedicated men and 
women can be proud of their contri- 
butions, which have helped take the 
United States Navy from biplanes to 
Sky lab. 



Volume 69, March 1978 



2B 



Professional 



Bruxism: Emotional Symptom or 
Dental Occlusal Problem? 

LCDR Steven G. Detsch, DC, USN 



Bruxism is a nonconscious, emotionally based or 
neurogenically related habit of grinding, clenching, 
clamping, or pressing the teeth together. It can occur 
while a person is awake or asleep. Like other oral 
habits— such as tongue thrusting or biting the fin- 
gernails, lip, or a hard object— bruxism is a frequent- 
ly repeated practice that may injure the teeth, their 
attachment apparatus, or the temporomandibular 
joint. The original term "la Bruxomanie" was coined 
in 1907 by Marie and Pietkiewicz (1) to designate 
habitual gritting of the teeth, which was thought to 
be caused by certain cortical brain lesions. The term 
"bruxomania" is now reserved to describe grinding 
of the teeth as a neurotic symptom. 

The etiology of bruxism is unknown. Two mecha- 
nisms have been proposed: first, that bruxism is an 
outlet for emotional or psychic stress; second, that it 
is caused by an increase in neuromuscular irritability 
due to occlusal disharmonies. Ramfjord (2,3) 
believes that both mechanisms are necessary to 
produce bruxism. 

It is quite possible that bruxism occurs universally 
—that almost every person occasionally, when under 
stress, will press or grind his teeth. Various studies 
quote incidences of 80% to 90% [2,3,4); however, 
most patients are unaware of the habit, and a case 
history is therefore unreliable. Perhaps more indica- 
tive of bruxism 's prevalence is the 98% occurrence 
of occlusal wear facets on adult teeth (5) . 

Considering the prevalence of bruxism, the fact 
that a person may press or grind his teeth while 
under stress is of little significance unless there are 

LCDR Detsch is a second-year resident in periodontics at the 
National Naval Dental Center, Bethesda, Md. 20014. 



signs or symptoms of trauma in the masticatory 
system. Clinical and radiographic signs compiled 
from several authors (2,3,6,7) are listed in Tables I 
and II. 

Bruxism has been indicted as a principal cause of 
temporomandibular joint (TMJ) myofacial pain 
dysfunction syndrome (8). An increase in bruxism 
has been observed shortly before the onset of TMJ 
symptoms (9). But while bruxism may produce oc- 
clusal trauma, it does not produce periodontal 
pockets and has no effect on the gingiva, 

Ramfjord (3) states that any signs and symptoms 
of bruxism elicited from a patient during examina- 
tion should be brought to the patient's attention, 
whereupon ' 'the habit will often be brought up to the 
conscious level and a positive history of bruxism may 
be obtained at a subsequent appointment. ' ' 

POSSIBLE CAUSES 

Mikami (9) believes that bruxism may relieve 
mental or physical stress. He hypothesizes that "the 
teeth of bruxists serve as a release mechanism for 
overt aggression." In other words, bruxism is "a 
mechanism for achieving gratification for blocked 
drives and desires" in a socially invisible, internal, 
and acceptable mode. 

Although Reding et al (10) found no significant 
personality differences between nocturnal bruxers 
and controls, an interesting psychological profile 
may be compiled from the Olkinuora studies (11,12) 
of 69 bruxers and 42 controls. In comparison with the 
controls, the bruxers were found to be more meticu- 
lous, more successful in school, more emotionally 
unstable, and more tense in special situations. Also, 



26 



U.S. Navy Medicine 



TABLE I. Clinical Signs and Symptoms of Bruxism 



Non masticatory patterns of occlusal wear of teeth. 

• Incisal or occlusal attrition: Facets, flattening of incisal 

tips of cuspids, fraying of incisal edges of central and 
lateral incisors. (Wear can occur on both natural and 
artificial teeth.) 

• Cupping of exposed dentin associated with severe wear. 

• Severe attrition, leading to: 

Loss of vertical dimension. 

• Loss of marginal ridges, producing open contacts and 
areas of food impaction. 
Loss of holding contacts. 

Unexpected fractures of teeth and restorations; cracked teeth 
or chipped enamel. 

Unexpected mobility of teeth. 

• General or localized mobility. 

• Fremitus. 

• Migration of teeth; fanning of anterior teeth, 

Pulpal hyperemia with sensitivity, especially to cold. 
Dull percussion sound from teeth. 
Soreness of teeth to biting stress. 



Increased muscle tonus; hypertrophy of masticatory muscles, 
especially the masseter; and uncontrolled resistance to ma- 
nipulation of mandible. 

Soreness of masticatory muscles to palpation. 

Feeling of fatigue in jaw muscles when patient awakens. 

Locking of jaws. 

Biting of lips, cheeks, fingernails, or hard objects like pens, 
pencils, and eyeglass frames. 

Pain in temporomandibular joint, or history of subluxation. 

Tension or emotional headaches associated with abnormal 
muscle tension. 

Maxillary and mandibular exostoses. 

Periodontal abscess formation. 

Audible nocturnal grinding. 



bruxers suffered more from headaches and muscle 
pains, and they felt more isolation. Most of the 
bruxers were females. The presence of this habit in 
the bruxers was predicted by the Alanen Rating 
Scale (a measure of emotional disturbance). 

Nadler (4) mentioned several occupational^ 
related sources of bruxism: for example, people 
engaged in precise and meticulous work, "such as 
watchmakers, die makers, machinists, and diamond 
cleavers," may clench their teeth as a relief from 
mental tension. Others likely to clench their teeth are 
athletes in strenuous competition, motorists apply- 
ing the brakes, or housewives trying to open a jar. 
Similarly, children may grind or clench their teeth 
while studying, during examinations, as a reaction to 
pain, or when rejected by playmates. Nadler thought 
that chewing gum or tobacco, and biting or chewing 
pencils, toothpicks, pipestems, or bobby pins might 
all be considered forms of bruxism. 

Bruxism's association with sleep is interesting. 
Several authors (13-17) relate bruxism to periods of 
stage V rapid eye movement sleep (REMS), which 
has been linked to dreaming. During REMS, a 
paradox occurs. Muscle tension increases in the jaw 
while the neck, trunk, and limb muscles— after a few 
quivering, or myoclonic, movements— become com- 
pletely slack (17). A person will go through four to 



TABLE II. Radiographic Signs of Bruxism 

Widening of periodontal ligament space. 

Ftoot resorption. 

Hypercementosis. 

Osteosclerosis. 

Root fracture. 

Uneven thickening or complete loss of lamina dura. 

Angular bone loss and bone loss in furcation areas of mutt 
rooted teeth. 






six REMS periods, at intervals of approximately 90 
minutes, in the course of a night's sleep. In REMS, 
which occupies about 20% of the total period of 
sleep, contractions of the masseter muscles occur at 
a rate of 20.9 per hour as compared to 5.3 per hour 
during non-REMS periods. 

Robinson et al (18) postulate that nocturnal 
grinding of teeth is associated with all stages of 
sleep, with a preponderance in stage II or partial 
arousal from sleep, which is akin to sleepwalking, 
neurosis, and nightmare. This phenomenon would 



Volume 69, March 1978 



27 



indicate that bruxism could be triggered by sleep- 
disturbing stimuli. 

Cluster headaches— a variety of migraine or 
vascular headaches— also often develop at night or 
in periods of dozing, and especially during REMS 
{19). 

Ramfjord (3), in his electromyographic study, 
made the association between occlusal interferences, 
which he labeled trigger factors, and an increase in 
hypertonicity or irritability of muscles. Ramfjord's 
trigger factors were: 

• discrepancy between centric relation and centric 
occlusion. 

• balancing side and working side interferences. 

• gingival flaps on third molars. 

• gingival hyperplasia. 

• TMJ or muscle pain. 

• surface irregularities of tongue, cheek, or lips. 

• relation of tooth roots to maxillary sinus. 
Ramfjord also stated that although the neuromus- 
cular control is highly adaptive and can learn to avoid 
occlusal interferences, it is much more difficult to 
avoid interference related to swallowing. In bruxers, 
he observed a disturbed contraction pattern during 
swallowing, and hypothesized that this disturbance 
was caused by a slide from centric relation to centric 
occlusion. 

Once the irritability threshold of muscle is 
reached, overfatigue and pain from sustained con- 
traction perpetuates the hyper irritability. Ramfjord 
thought that bruxism could be eliminated by remov- 
ing occlusal discrepancies, which would break this 
cycle . He was able to show a return to normal muscle 
tonus, as measured by the electromyograph, follow- 
ing occlusal adjustment in bruxers. 

Dawson (20) and others (21) went further and said 
that if bruxism was not eliminated by occlusal adjust- 
ment the practitioner was performing the procedure 
improperly. This premise overlooks the incidence of 
bruxism in patients with no occlusal anomalies, in 
edentulous babies or adults, and in people with any 
of numerous systemic problems, including nephritis, 
meningitis, dementia epilepsy, chorea, and cerebral 
spastic infantile paralysis. The concept that tooth 
contact in chewing and most swallowing occurs in 
habitual occlusion and only occasionally in centric 
relation (22) also throws some doubt on the occlusal 
origin of bruxism. 

As dentists, we find it easier to locate abnormali- 
ties of occlusion than to identify predisposing sys- 
temic or emotional factors (23) . This does not mean 
that occlusion is the sole etiologic factor. Occlusal 
dysfunction is extremely common, but only a small 



percentage of patients who have it develop severe 
signs and symptoms or TMJ disorders. Neverthe- 
less, abnormal muscle contraction and joint dis- 
orders usually respond to occlusal therapy. Underly- 
ing emotional disorders should, however, also be 
treated. 

TREATMENT 

Mikami (9) sets four objectives in the treatment of 
bruxism: "(1) reduce psychic tension, (2) treat the 
signs and symptoms, (3> minimize occlusal irrita- 
tions, and (4) break neuromuscular habit patterns." 

Treatment must be geared to the degree of 
severity of the bruxism. If there are minimal signs or 
symptoms, the dentist need render little or no treat- 
ment aside from listening to the patient and acknowl- 
edging that he cares if the patient has a particularly 
stressful problem. But as the patient's symptoms 
increase, other modes of treatment may be con- 
sidered. Treatments for reducing psychic tension in- 
clude: 

• therapist's empathy with the patient. 

• education of the patient. 

• hypnosis and autosuggestion. 

• tranquilizing agents. 

• suggestions for hobbies or vacations. 

• recommendations for modifying an uncomfortable 
sleep environment. 

• relaxation therapy. 

• psychotherapy. 

Bell (24) suggested the following treatments for 
bruxism: 

• occlusal splint or night guard. 

• occlusal adjustment (prophylactic adjustments of 
occlusion are not indicated in the absence of symp- 
toms). 

• hot showers. 

• heat packs. 

• ultrasound. 

• ethyl chloride spray. 

• dry needle insertion into muscle. 

• injections of lidocaine. 

• exercises. 

• drug therapy. 

Mikami's (9) conclusion is most apt: 
Habits resulting from lifelong neuroses are difficult to extin- 
guish, since bruxism is a socially acceptable stress-releasing 
activity. Our dental therapeutic measures strive to decrease the 
levels of mental and occlusal stress below some unknown 
threshold of stress in the individual. If this level is reached or 
exceeded, even after thorough dental care, the individual will 
likely resort to the same mechanism for stress release or dissipa- 
tion. Bruxism, then, is not permanently treated but merely 
managed. 



28 



U.S. Navy Medicine 



REFERENCES 

1. Marie MM, Pietkiewicz M: la Bruxomanie. Rev de Stomat 
14:107, 1907. 

2. Ramfjord SP, Ash MM Jr: Occlusion ed. 2. Philadelphia: 
W.B. Saunders, 1971, pp 231-255. 

3. Ramfjord SP: Bruxism, a clinical and electromyographic 
study. J Am Dent Assoc 62:21-44, 1961. 

4. Nadler SC: Bruxism, a classification: critical review. J Am 
Dent Assoc 54:615-622, 1957. 

5. Weinberg LA: Diagnosis of facets in occlusal equilibration. 
J Am Dent Assoc 52:26-35, 1956. 

6. Bowers GM, Lawrence JJ, Williams JE Jr: Periodontics 
Syllabus, NAVMED P-5110. Washington: U.S. Government 
Printing Office, 1975. 

7. Sugarman MM, Sugarman EF: Bruxism and occlusal 
traumatism, diagnosis and treatment. Northwest Dent 49:216- 
224, 1970. 

8. Bruno SA: Neuromuscular disturbances causing temporo- 
mandibular dysfunction and pain. J Prosthet Dent 26:387-395, 
1971. 

9. Mikami DB: A review of psychogenic aspects and treat- 
ment of bruxism. J Prosthet Dent 37:411-419, 1977. 

10. Reding GR, et al: Personality study of nocturnal teeth 
grinders. Percept Mot Skills 26:523-533, 1968. 

11. Olkinuora M: Psychological aspects in a series of bruxists 
compared with a group of nonbruxists. Soum Hammaslaak Toim 
68:200-208, 1972. 



12. Olkinuora M: A psychosomatic study of bruxism with 
emphasis on mental strain and familiar predisposition factors. 
Soum Hammaslaak Toim 68:112-123, 1972. 

13. Reding GR, et al: Relation between bruxism and dream- 
ing. Dent Abst 9:707, 1964. 

14. Ganong WF: Review of Medical Physiology. Los Altos: 
Lang, 1967, pp 127-139. 

15. Powell RN: Tooth contact during sleep: association with 
other events. J Dent Res 44:959-967, 1965. 

16. Guyton AC: Textbook of Medical Physiology , ed 4. Phila- 
delphia: W.B. Saunders, 1971, pp 707-709. 

17. Thorn GW, et al: Harrison's Principles of Internal Medi- 
cine, ed 8. New York: McGraw-Hill, 1977, pp 122-127. 

18. Robinson JE, et al: Nocturnal teeth-grinding: a reassess- 
ment for dentistry. J Am Dent Assoc 78:1308-1311, 1969. 

19. Packard RC: Cluster headache. US Nav Med 67(41:17, 
1976. 

20. Dawson PE: Temporomandibular joint pain— dysfunction 
problems can be solved. J Prosthet Dent 29:100-112, 1973. 

21. Guichet NF: Occlusion, A Collection of Monographs. 
Anaheim: Denar Corp, 1970, pp 83-87. 

22. Glickman I, et al: Functional occlusion as revealed by 
miniaturized radiotransmitters. Dent Clin North Am 13:667-679, 
1969. 

23. Glickman 1: Clinical Periodontohgy, ed 4. Philadelphia: 
W.B. Saunders, 1972, pp 827-851. 

24. Bell WH: Nonsurgical management of the pain-dysfunc- 
tion syndrome. J Am Dent Assoc 79:161-170, 1969. 



Laboratory Techniques 



Gram Stain Interpretation in Detecting GC 



In reporting the results of gram 
stains for Neisseria gonorrhoeae. 
Medical Department representa- 
tives must realized the limitations of 
the stain alone, and must be aware 
of the restrictions on interpretation 
of clinical or laboratory data when 
services for definitive identification 
are not available. 

The method for reporting the re- 
sults of a gram stain examination is 
extremely important, and a semi- 
quantitative reporting system, de- 
veloped by agreement with those 
the laboratory serves, is suggested. 

The report should include the 
presence and amount of polymor- 
phonuclear leukocytes (PMNs) and 
epithelial cells. It should also indi- 
cate the morphology, staining char- 
acteristics, numbers and location 
(i.e., intracellular) of all bacteria 
seen. The following system is sug- 
gested for uniformity: 



4+ = more than 30 cells per oil 
immersion field 
3+ = 5-30 cells per oil immer- 
sion field 

2+ = 1-5 cells per oil immer- 
sion field 

1 + = less than 1 cell per oil im- 
mersion field 

The use of the term "gram-nega- 
tive intracellular diplococci" should 
be applied only when the micro- 
scopic appearance is consistent with 
that of acute gonorrhea in the male, 
with several pairs of gram-negative 
kidney-shaped diplococci within 
individual PMNs. Coccoid forms 
that are not gonococci are some- 
times seen attached to or within 
leukocytes. These may be short 
forms of gram-negative rods or 
gram-positive cocci which have 
either lost their staining properties 
or been over-decolorized. 



Culture. One should always col- 
lect a culture when dealing with 
urethritis where gonorrhea is a pos- 
sibility. The culture will aid diagno- 
sis where gram stains are inconclu- 
sive or perhaps misinterpreted, and 
it is a "must" when test-of-cure 
exams are performed. The gram 
stain on an early test-of-cure culture 
may have gram-negative diplococci 
that are actually nonviable Neisseria 
organisms. Unless a proper culture 
is taken, nothing can be said about 
the viability of these organisms; 
therefore, evidence for effective 
treatment is inconclusive. 

Finally, one must realize that 
there is no specificity for each indi- 
vidual smear; thus, only what is 
seen should be reported. Diagnosis 
should be aided by extensive labo- 
ratory confirmation. 

— Adapted from the Pacific Health Bulle- 
tin. Nov 1977 



Volume 69, March 1978 



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